Provider Demographics
NPI:1245758564
Name:EMBRY, KELSEY LILLARD (PLMSW)
Entity type:Individual
Prefix:MRS
First Name:KELSEY
Middle Name:LILLARD
Last Name:EMBRY
Suffix:
Gender:F
Credentials:PLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 647
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72078-0647
Mailing Address - Country:US
Mailing Address - Phone:501-982-5402
Mailing Address - Fax:501-533-6378
Practice Address - Street 1:2411 W. MAIN ST.
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72076-8868
Practice Address - Country:US
Practice Address - Phone:501-982-5402
Practice Address - Fax:501-533-6378
Is Sole Proprietor?:No
Enumeration Date:2017-09-07
Last Update Date:2017-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPLMSW1041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARPLMSWMedicaid