Provider Demographics
NPI:1336614007
Name:GAINES, KELLI LAUREN
Entity Type:Individual
Prefix:MISS
First Name:KELLI
Middle Name:LAUREN
Last Name:GAINES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5017 QUEENS STROLL PL SE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20019-6103
Mailing Address - Country:US
Mailing Address - Phone:202-246-2487
Mailing Address - Fax:
Practice Address - Street 1:5017 QUEENS STROLL PL SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20019-6103
Practice Address - Country:US
Practice Address - Phone:202-246-2487
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-09
Last Update Date:2018-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician