Basic Information
| Provider Information | |||||||||
| NPI: | 1245570092 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SPEED | ||||||||
| FirstName: | KELLIE | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | MS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 19101 | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711490101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8324215199 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 9403 MANSFIELD RD | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711183815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3188618938 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2013 | ||||||||
| LastUpdateDate: | 11/01/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor |
No ID Information.