Provider Demographics
NPI:1720634512
Name:TYLER, KELLY NADINE
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:NADINE
Last Name:TYLER
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 1:2303 GRAVIER ST
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70119-7523
Mailing Address - Country:US
Mailing Address - Phone:504-234-9678
Mailing Address - Fax:
Practice Address - Street 1:200 S BROAD ST STE 7
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70119-6447
Practice Address - Country:US
Practice Address - Phone:504-309-9991
Practice Address - Fax:504-821-0609
Is Sole Proprietor?:No
Enumeration Date:2019-08-16
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA7521101Y00000X
LAPLC7521171M00000X
101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator