Provider Demographics
NPI:1124849070
Name:LEVY, KISHA DONIELLE
Entity type:Individual
Prefix:
First Name:KISHA
Middle Name:DONIELLE
Last Name:LEVY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KISHA
Other - Middle Name:DONIELLE
Other - Last Name:DEGRAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PLPC
Mailing Address - Street 1:1604 DEHART DR APT A
Mailing Address - Street 2:
Mailing Address - City:NEW IBERIA
Mailing Address - State:LA
Mailing Address - Zip Code:70560-7063
Mailing Address - Country:US
Mailing Address - Phone:850-212-8852
Mailing Address - Fax:
Practice Address - Street 1:224 SAINT LANDRY ST STE 2C
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70506-3578
Practice Address - Country:US
Practice Address - Phone:337-716-5170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-23
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPLC10432101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health