Provider Demographics
NPI:1093774879
Name:KELLEY, LLOYD THURSTON (LCSW)
Entity Type:Individual
Prefix:
First Name:LLOYD
Middle Name:THURSTON
Last Name:KELLEY
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 123977 DEPT 3977 150
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75312-0001
Mailing Address - Country:US
Mailing Address - Phone:337-494-2772
Mailing Address - Fax:337-494-2928
Practice Address - Street 1:2829 4TH AVE STE 150
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-7897
Practice Address - Country:US
Practice Address - Phone:337-480-7800
Practice Address - Fax:337-474-4552
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-21
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA12441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2509551Medicaid
LA1244OtherSTATE LICENSE