Provider Demographics
NPI:1922181601
Name:KELLICUT, LAURA ANN (MA)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:ANN
Last Name:KELLICUT
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:ANN
Other - Last Name:ODELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 9054
Mailing Address - Street 2:
Mailing Address - City:GRAY
Mailing Address - State:TN
Mailing Address - Zip Code:37615-9054
Mailing Address - Country:US
Mailing Address - Phone:423-467-3600
Mailing Address - Fax:423-467-3644
Practice Address - Street 1:109 W WATAUGA AVE
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-5621
Practice Address - Country:US
Practice Address - Phone:423-232-2600
Practice Address - Fax:423-467-3644
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2012-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
TNLPC2799101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No171M00000XOther Service ProvidersCase Manager/Care Coordinator