Provider Demographics
NPI:1801001904
Name:KINGSLEY HOUSE INC
Entity Type:Organization
Organization Name:KINGSLEY HOUSE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:
Authorized Official - Last Name:LIEDERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:504-523-6221
Mailing Address - Street 1:1600 CONSTANCE STREET
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70130-4641
Mailing Address - Country:US
Mailing Address - Phone:504-523-6221
Mailing Address - Fax:504-523-4450
Practice Address - Street 1:1600 CONSTANCE STREET
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70130-4641
Practice Address - Country:US
Practice Address - Phone:504-523-6221
Practice Address - Fax:504-523-4450
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA0002525261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1317306Medicaid