Provider Demographics
NPI:1760155717
Name:STELLY, LAURA ANNETTE (RLT)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:ANNETTE
Last Name:STELLY
Suffix:
Gender:F
Credentials:RLT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2036 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71301-6439
Mailing Address - Country:US
Mailing Address - Phone:318-641-0444
Mailing Address - Fax:
Practice Address - Street 1:813 BON AMI ST
Practice Address - Street 2:
Practice Address - City:DERIDDER
Practice Address - State:LA
Practice Address - Zip Code:70634-5529
Practice Address - Country:US
Practice Address - Phone:337-466-9047
Practice Address - Fax:318-641-6118
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-27
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAR-7595106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician