Provider Demographics
NPI:1417276528
Name:WEBB, KELLIE RENE (LAT)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:RENE
Last Name:WEBB
Suffix:
Gender:F
Credentials:LAT
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 638
Mailing Address - Street 2:
Mailing Address - City:FORT WASHAKIE
Mailing Address - State:WY
Mailing Address - Zip Code:82514-0638
Mailing Address - Country:US
Mailing Address - Phone:307-332-2203
Mailing Address - Fax:307-335-8108
Practice Address - Street 1:28 BLACK COLE DRIVE
Practice Address - Street 2:
Practice Address - City:FT. WASHAKIE
Practice Address - State:WY
Practice Address - Zip Code:82514-0638
Practice Address - Country:US
Practice Address - Phone:307-332-2203
Practice Address - Fax:307-335-8108
Is Sole Proprietor?:No
Enumeration Date:2010-05-28
Last Update Date:2010-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYLAT-222101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)