Provider Demographics
NPI:1174658801
Name:KELLY, LAUREN LURLINE (EDS)
Entity Type:Individual
Prefix:MS
First Name:LAUREN
Middle Name:LURLINE
Last Name:KELLY
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1750 W THUNDERBIRD RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85023-6307
Mailing Address - Country:US
Mailing Address - Phone:623-915-8949
Mailing Address - Fax:623-915-8971
Practice Address - Street 1:1750 W THUNDERBIRD RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85023-6307
Practice Address - Country:US
Practice Address - Phone:623-915-8949
Practice Address - Fax:623-915-8971
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-22
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool