Provider Demographics
NPI:1568979797
Name:MATHERNE, KELLY POWELL (LPC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:POWELL
Last Name:MATHERNE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 COUNTRY VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:RACELAND
Mailing Address - State:LA
Mailing Address - Zip Code:70394-2009
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 COUNTRY VILLAGE DR
Practice Address - Street 2:
Practice Address - City:RACELAND
Practice Address - State:LA
Practice Address - Zip Code:70394-2009
Practice Address - Country:US
Practice Address - Phone:985-688-4247
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-09
Last Update Date:2018-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5577101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional