Provider Demographics
NPI:1558611905
Name:RENFRO, KELLI DEAN
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:DEAN
Last Name:RENFRO
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 1:768 CHEVELLE DR
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70806-6503
Mailing Address - Country:US
Mailing Address - Phone:225-930-0208
Mailing Address - Fax:225-930-0221
Practice Address - Street 1:768 CHEVELLE DR
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806-6503
Practice Address - Country:US
Practice Address - Phone:225-930-0208
Practice Address - Fax:225-930-0221
Is Sole Proprietor?:No
Enumeration Date:2012-09-13
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA6747235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist