Provider Demographics
NPI:1689970436
Name:KELLEY, LA VAUN (LPC)
Entity Type:Individual
Prefix:
First Name:LA VAUN
Middle Name:
Last Name:KELLEY
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 1:712 FORREST COVE CT
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37040-5779
Mailing Address - Country:US
Mailing Address - Phone:931-302-4519
Mailing Address - Fax:
Practice Address - Street 1:2515 WILMA RUDOLPH BLVD
Practice Address - Street 2:SUITE 107
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37040-5844
Practice Address - Country:US
Practice Address - Phone:931-302-4519
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-26
Last Update Date:2012-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701004981101YP2500X
TN1975101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional