Provider Demographics
NPI:1447401161
Name:KELLY, STEPHANIE ROSE (MSW, LCSW)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:ROSE
Last Name:KELLY
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:MISS
Other - First Name:STEPHANIE
Other - Middle Name:ROSE
Other - Last Name:NASSRAH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:2601 TULANE AVE
Mailing Address - Street 2:SUITE 500
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70119-7462
Mailing Address - Country:US
Mailing Address - Phone:504-821-2601
Mailing Address - Fax:504-821-2040
Practice Address - Street 1:2601 TULANE AVE
Practice Address - Street 2:SUITE 500
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70119-7462
Practice Address - Country:US
Practice Address - Phone:504-821-2601
Practice Address - Fax:504-821-2040
Is Sole Proprietor?:No
Enumeration Date:2008-10-01
Last Update Date:2012-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA88961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA3A858OtherMEDICARE PTAN
LA1352462Medicaid