Provider Demographics
NPI:1154534097
Name:CHURCHILL, KELLI (LCSW)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:CHURCHILL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1925 AMERICA ST
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70448-3802
Mailing Address - Country:US
Mailing Address - Phone:985-630-8350
Mailing Address - Fax:
Practice Address - Street 1:5001 HIGHWAY 190 EAST SERVICE RD STE B1
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-4999
Practice Address - Country:US
Practice Address - Phone:985-630-8350
Practice Address - Fax:985-867-3438
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2012-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA77351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical