Provider Demographics
NPI:1417328246
Name:BETTIS, KEMJA
Entity Type:Individual
Prefix:
First Name:KEMJA
Middle Name:
Last Name:BETTIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4325 CLUBHOUSE DR APT H2
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71303-3572
Mailing Address - Country:US
Mailing Address - Phone:720-633-0949
Mailing Address - Fax:
Practice Address - Street 1:1900 N 18TH ST, MORORE, LA
Practice Address - Street 2:
Practice Address - City:MONORE
Practice Address - State:LA
Practice Address - Zip Code:71201
Practice Address - Country:US
Practice Address - Phone:720-633-0949
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-20
Last Update Date:2018-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA12845104100000X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No104100000XBehavioral Health & Social Service ProvidersSocial Worker