Provider Demographics
NPI:1225489776
Name:KILLINGSWORTH, SHELLY (MS)
Entity Type:Individual
Prefix:MRS
First Name:SHELLY
Middle Name:
Last Name:KILLINGSWORTH
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:329 TEAKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:YOUNGSVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70592-5223
Mailing Address - Country:US
Mailing Address - Phone:337-789-0442
Mailing Address - Fax:337-345-1576
Practice Address - Street 1:118 EXCHANGE PL
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-2510
Practice Address - Country:US
Practice Address - Phone:337-789-0442
Practice Address - Fax:337-345-1576
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-27
Last Update Date:2020-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
6643101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty