Provider Demographics
NPI:1538850417
Name:TAYLOR, KELLEY (LAC)
Entity type:Individual
Prefix:
First Name:KELLEY
Middle Name:
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:354 PINE RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:DERIDDER
Mailing Address - State:LA
Mailing Address - Zip Code:70634-5350
Mailing Address - Country:US
Mailing Address - Phone:337-226-7504
Mailing Address - Fax:
Practice Address - Street 1:315 ALAMO ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-8528
Practice Address - Country:US
Practice Address - Phone:337-226-7504
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-19
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5135101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)