Basic Information
| Provider Information | |||||||||
| NPI: | 1659750081 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | KELLEY | ||||||||
| MiddleName: | SIMONE | ||||||||
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| Credential: | CSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1828 VIRGINIAN COLONY AVE | ||||||||
| Address2: | |||||||||
| City: | LA PLACE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 700682842 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 330 N JEFFERSON DAVIS PKWY | ||||||||
| Address2: | |||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 701195312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5049486880 | ||||||||
| FaxNumber: | 5049486885 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2015 | ||||||||
| LastUpdateDate: | 11/09/2015 | ||||||||
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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 | 104100000X | 13250 | LA | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.