Provider Demographics
NPI:1437159639
Name:RAY, KELLY PAULK (PHD, MP)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:PAULK
Last Name:RAY
Suffix:
Gender:F
Credentials:PHD, MP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7913 WRENWOOD BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-1793
Mailing Address - Country:US
Mailing Address - Phone:225-763-6300
Mailing Address - Fax:225-763-9358
Practice Address - Street 1:7913 WRENWOOD BLVD STE A
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809
Practice Address - Country:US
Practice Address - Phone:225-763-6300
Practice Address - Fax:225-763-9358
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2019-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMP.0862103TP0016X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1474657Medicaid