Provider Demographics
NPI:1578033387
Name:BENNETT, KELLY S
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:S
Last Name:BENNETT
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:KELLY
Other - Middle Name:B
Other - Last Name:FELTES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:11100 HIGHWAY 1078
Mailing Address - Street 2:
Mailing Address - City:FOLSOM
Mailing Address - State:LA
Mailing Address - Zip Code:70437-3501
Mailing Address - Country:US
Mailing Address - Phone:985-264-2253
Mailing Address - Fax:
Practice Address - Street 1:11100 HIGHWAY 1078
Practice Address - Street 2:
Practice Address - City:FOLSOM
Practice Address - State:LA
Practice Address - Zip Code:70437-3501
Practice Address - Country:US
Practice Address - Phone:985-264-2253
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-05
Last Update Date:2019-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA005978211101YM0800X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health