Provider Demographics
NPI:1922643832
Name:KERN, KELLI DENISE (RSW, MED)
Entity Type:Individual
Prefix:MRS
First Name:KELLI
Middle Name:DENISE
Last Name:KERN
Suffix:
Gender:F
Credentials:RSW, MED
Other - Prefix:MISS
Other - First Name:KELLI
Other - Middle Name:DENISE
Other - Last Name:CORLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RSW
Mailing Address - Street 1:1000 CHINABERRY DR STE 900
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-2455
Mailing Address - Country:US
Mailing Address - Phone:318-675-0804
Mailing Address - Fax:318-425-9030
Practice Address - Street 1:305 E MISSISSIPPI AVE # 900
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-3905
Practice Address - Country:US
Practice Address - Phone:318-202-3706
Practice Address - Fax:318-202-3707
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-14
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
LA5018104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No104100000XBehavioral Health & Social Service ProvidersSocial Worker