Provider Demographics
NPI:1386292340
Name:STEPHENSON, KELLI SUE
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:SUE
Last Name:STEPHENSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:829 E GEORGIA AVE
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71270-3912
Mailing Address - Country:US
Mailing Address - Phone:318-242-0730
Mailing Address - Fax:
Practice Address - Street 1:829 E GEORGIA AVE
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-3912
Practice Address - Country:US
Practice Address - Phone:318-242-0730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-03
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator