Provider Demographics
NPI:1235661323
Name:FERRELL, KEWON HIKEEM
Entity type:Individual
Prefix:
First Name:KEWON
Middle Name:HIKEEM
Last Name:FERRELL
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 1:200 N THOMAS DR
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71107-6503
Mailing Address - Country:US
Mailing Address - Phone:318-424-8345
Mailing Address - Fax:
Practice Address - Street 1:200 N THOMAS DR
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71107-6503
Practice Address - Country:US
Practice Address - Phone:318-424-8345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-29
Last Update Date:2017-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA522089886Medicaid