Provider Demographics
NPI:1417496514
Name:KELLEY, TAMRA
Entity Type:Individual
Prefix:
First Name:TAMRA
Middle Name:
Last Name:KELLEY
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 1:4650 LAKESHORE DR
Mailing Address - Street 2:APT 102
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71109-2925
Mailing Address - Country:US
Mailing Address - Phone:318-200-3315
Mailing Address - Fax:
Practice Address - Street 1:4650 LAKESHORE DR
Practice Address - Street 2:APT 102
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71109-2925
Practice Address - Country:US
Practice Address - Phone:318-200-3315
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-22
Last Update Date:2017-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health