Provider Demographics
NPI:1902179336
Name:BEATTY, KENNETH ELGIN
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:ELGIN
Last Name:BEATTY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6225 DILLINGHAM AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-3303
Mailing Address - Country:US
Mailing Address - Phone:318-865-4967
Mailing Address - Fax:
Practice Address - Street 1:864 OLIVE ST
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71104-2159
Practice Address - Country:US
Practice Address - Phone:318-222-0759
Practice Address - Fax:318-221-0216
Is Sole Proprietor?:No
Enumeration Date:2012-02-15
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional