Basic Information
| Provider Information | |||||||||
| NPI: | 1447401161 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLY | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | ROSE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MSW, LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | NASSRAH | ||||||||
| OtherFirstName: | STEPHANIE | ||||||||
| OtherMiddleName: | ROSE | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LCSW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2601 TULANE AVE | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 701197462 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5048212601 | ||||||||
| FaxNumber: | 5048212040 | ||||||||
| Practice Location | |||||||||
| Address1: | 2601 TULANE AVE | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 701197462 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5048212601 | ||||||||
| FaxNumber: | 5048212040 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2008 | ||||||||
| LastUpdateDate: | 04/11/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 8896 | LA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 3A858 | 01 | LA | MEDICARE PTAN | OTHER | 1352462 | 05 | LA | MEDICAID |