Provider Demographics
NPI:1851053771
Name:MALLARY, KELLY LAURO (LPC-S)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:LAURO
Last Name:MALLARY
Suffix:
Gender:F
Credentials:LPC-S
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:MARIE
Other - Last Name:LAURO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC-S
Mailing Address - Street 1:600 CREOLE DR
Mailing Address - Street 2:
Mailing Address - City:MADISONVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70447-9243
Mailing Address - Country:US
Mailing Address - Phone:504-220-7927
Mailing Address - Fax:
Practice Address - Street 1:23515 HIGHWAY 190
Practice Address - Street 2:
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70448-7334
Practice Address - Country:US
Practice Address - Phone:985-626-6300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-07
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3962101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health