Provider Demographics
NPI:1083141188
Name:KELLY, KELYSHIA JEWAN (SLPA)
Entity Type:Individual
Prefix:MS
First Name:KELYSHIA
Middle Name:JEWAN
Last Name:KELLY
Suffix:
Gender:F
Credentials:SLPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57997 BARROW ST
Mailing Address - Street 2:
Mailing Address - City:PLAQUEMINE
Mailing Address - State:LA
Mailing Address - Zip Code:70764-4107
Mailing Address - Country:US
Mailing Address - Phone:225-241-8876
Mailing Address - Fax:
Practice Address - Street 1:57997 BARROW ST
Practice Address - Street 2:
Practice Address - City:PLAQUEMINE
Practice Address - State:LA
Practice Address - Zip Code:70764-4107
Practice Address - Country:US
Practice Address - Phone:225-241-8876
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA6423235Z00000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1255705828Medicaid