Provider Demographics
NPI:1194537597
Name:CEDOTAL, KILEY P (LCSW-BACS, FACHE)
Entity type:Individual
Prefix:
First Name:KILEY
Middle Name:P
Last Name:CEDOTAL
Suffix:
Gender:M
Credentials:LCSW-BACS, FACHE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:532 PONDEROSA DR
Mailing Address - Street 2:
Mailing Address - City:PONCHATOULA
Mailing Address - State:LA
Mailing Address - Zip Code:70454-9428
Mailing Address - Country:US
Mailing Address - Phone:225-715-8768
Mailing Address - Fax:
Practice Address - Street 1:532 PONDEROSA DR
Practice Address - Street 2:
Practice Address - City:PONCHATOULA
Practice Address - State:LA
Practice Address - Zip Code:70454-9428
Practice Address - Country:US
Practice Address - Phone:225-715-8768
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-22
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA61811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical