Provider Demographics
NPI:1730101197
Name:WOODS, KELLY DEMETRIUS (PHD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:DEMETRIUS
Last Name:WOODS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8120 MARTIN BLUFF RD
Mailing Address - Street 2:
Mailing Address - City:GAUTIER
Mailing Address - State:MS
Mailing Address - Zip Code:39553-2215
Mailing Address - Country:US
Mailing Address - Phone:228-497-9341
Mailing Address - Fax:228-523-4754
Practice Address - Street 1:400 VETERANS AVE
Practice Address - Street 2:(116B)
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39531-2410
Practice Address - Country:US
Practice Address - Phone:228-523-4734
Practice Address - Fax:228-523-4754
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS36 653103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical