Provider Demographics
NPI:1619526597
Name:THOMAS, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:THOMAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 ROSELAWN DR
Mailing Address - Street 2:
Mailing Address - City:NATCHEZ
Mailing Address - State:MS
Mailing Address - Zip Code:39120-4069
Mailing Address - Country:US
Mailing Address - Phone:601-870-3905
Mailing Address - Fax:601-442-9294
Practice Address - Street 1:11 ROSELAWN DR
Practice Address - Street 2:
Practice Address - City:NATCHEZ
Practice Address - State:MS
Practice Address - Zip Code:39120-4069
Practice Address - Country:US
Practice Address - Phone:601-392-8706
Practice Address - Fax:601-442-9294
Is Sole Proprietor?:No
Enumeration Date:2019-09-04
Last Update Date:2019-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health