Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YA0400X | Addiction Counselor (Substance Use Disorder) | 0656 | KY |
NPI | 1003215740 |
---|---|
Provider Name | Keith Mckenzie |
First Address | Louisville, KY 40202-2133 |
Second Address | Louisville, KY 40202-2133 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 19/08/2014 |
Last Update Date | 31/10/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
7100323580 | (05) | KY |