Provider Demographics
NPI:1407364409
Name:CASEY, KELLY JANE
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:JANE
Last Name:CASEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2620 CENTENARY BLVD STE 207
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71104-3350
Mailing Address - Country:US
Mailing Address - Phone:318-626-5657
Mailing Address - Fax:318-626-5658
Practice Address - Street 1:2620 CENTENARY BLVD STE 207
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71104-3350
Practice Address - Country:US
Practice Address - Phone:318-626-5657
Practice Address - Fax:318-626-5658
Is Sole Proprietor?:No
Enumeration Date:2018-01-12
Last Update Date:2018-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor