Basic Information
| Provider Information | |||||||||
| NPI: | 1922643832 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KERN | ||||||||
| FirstName: | KELLI | ||||||||
| MiddleName: | DENISE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RSW, MED | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CORLEY | ||||||||
| OtherFirstName: | KELLI | ||||||||
| OtherMiddleName: | DENISE | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RSW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1000 CHINABERRY DR STE 900 | ||||||||
| Address2: | |||||||||
| City: | BOSSIER CITY | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711112455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3186750804 | ||||||||
| FaxNumber: | 3184259030 | ||||||||
| Practice Location | |||||||||
| Address1: | 305 E MISSISSIPPI AVE # 900 | ||||||||
| Address2: | |||||||||
| City: | RUSTON | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712703905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182023706 | ||||||||
| FaxNumber: | 3182023707 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2019 | ||||||||
| LastUpdateDate: | 02/07/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator | 104100000X | 5018 | LA | N | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.