Provider Demographics
NPI:1073530903
Name:KELLY LINER DEROUEN, LPC-S, LMFT, NCC, NCSC, SUPERVISOR LLC
Entity Type:Organization
Organization Name:KELLY LINER DEROUEN, LPC-S, LMFT, NCC, NCSC, SUPERVISOR LLC
Other - Org Name:KELLY LINER DEROUEN
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:COUNSELOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:LINER
Authorized Official - Last Name:DEROUEN
Authorized Official - Suffix:
Authorized Official - Credentials:LPC-S,LMFT,NCC,NCSC,
Authorized Official - Phone:985-876-5748
Mailing Address - Street 1:547 BAYOU DULARGE ROAD
Mailing Address - Street 2:
Mailing Address - City:HOUMA
Mailing Address - State:LA
Mailing Address - Zip Code:70363
Mailing Address - Country:US
Mailing Address - Phone:985-876-5748
Mailing Address - Fax:
Practice Address - Street 1:547 BAYOU DULARGE ROAD
Practice Address - Street 2:
Practice Address - City:HOUMA
Practice Address - State:LA
Practice Address - Zip Code:70363
Practice Address - Country:US
Practice Address - Phone:985-876-5748
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-16
Last Update Date:2013-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchoolGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty