Provider Demographics
NPI:1508247768
Name:BAISE, KENOSHA
Entity Type:Individual
Prefix:MRS
First Name:KENOSHA
Middle Name:
Last Name:BAISE
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 1:77135 IBERVILLE DR
Mailing Address - Street 2:
Mailing Address - City:MARINGOUIN
Mailing Address - State:LA
Mailing Address - Zip Code:70757-3701
Mailing Address - Country:US
Mailing Address - Phone:225-317-1693
Mailing Address - Fax:
Practice Address - Street 1:77135 IBERVILLE DR
Practice Address - Street 2:
Practice Address - City:MARINGOUIN
Practice Address - State:LA
Practice Address - Zip Code:70757-3701
Practice Address - Country:US
Practice Address - Phone:225-317-1693
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-13
Last Update Date:2015-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst