Provider Demographics
NPI:1659750081
Name:PETERSON, KELLEY SIMONE (CSW)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:SIMONE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1828 VIRGINIAN COLONY AVE
Mailing Address - Street 2:
Mailing Address - City:LA PLACE
Mailing Address - State:LA
Mailing Address - Zip Code:70068-2842
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:330 N JEFFERSON DAVIS PKWY
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70119-5312
Practice Address - Country:US
Practice Address - Phone:504-948-6880
Practice Address - Fax:504-948-6885
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-18
Last Update Date:2015-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA13250104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker