Provider Demographics
NPI:1699308296
Name:KELLY, DAVID ANDREW (CIT-5052)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:ANDREW
Last Name:KELLY
Suffix:
Gender:M
Credentials:CIT-5052
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 4073
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70434-4073
Mailing Address - Country:US
Mailing Address - Phone:985-602-5253
Mailing Address - Fax:
Practice Address - Street 1:19411 HELENBIRG RD STE 101
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-5199
Practice Address - Country:US
Practice Address - Phone:985-985-3172
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-21
Last Update Date:2020-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5052101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)