Provider Demographics
NPI:1699532887
Name:TURNER, KELLY DIANE (LAC)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:DIANE
Last Name:TURNER
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:DIANE
Other - Last Name:COBLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2400 S 48TH ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72762-6683
Mailing Address - Country:US
Mailing Address - Phone:479-750-2020
Mailing Address - Fax:
Practice Address - Street 1:2205 PHYLLIS ST
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-6490
Practice Address - Country:US
Practice Address - Phone:479-725-6000
Practice Address - Fax:479-878-1966
Is Sole Proprietor?:No
Enumeration Date:2024-03-04
Last Update Date:2025-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARP2402013101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR316128795Medicaid