Provider Demographics
NPI:1881006641
Name:KELLEY, CANDICE LA'NAE (LAC)
Entity Type:Individual
Prefix:MRS
First Name:CANDICE
Middle Name:LA'NAE
Last Name:KELLEY
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 23070
Mailing Address - Street 2:
Mailing Address - City:BARLING
Mailing Address - State:AR
Mailing Address - Zip Code:72923-0070
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1340 S WALDRON RD
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-2556
Practice Address - Country:US
Practice Address - Phone:479-452-5040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-28
Last Update Date:2019-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator