Provider Demographics
NPI:1952815458
Name:LEWIS, KELLYE JEAN (MA, LPC, NCC)
Entity Type:Individual
Prefix:
First Name:KELLYE
Middle Name:JEAN
Last Name:LEWIS
Suffix:
Gender:F
Credentials:MA, LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 COLIN P KELLY DR
Mailing Address - Street 2:
Mailing Address - City:MINDEN
Mailing Address - State:LA
Mailing Address - Zip Code:71055-7912
Mailing Address - Country:US
Mailing Address - Phone:318-402-6379
Mailing Address - Fax:
Practice Address - Street 1:3821 SOUTHERN AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106-1033
Practice Address - Country:US
Practice Address - Phone:318-946-8157
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-21
Last Update Date:2017-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LALPC6093101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional