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NPI Code Detail

MEDICARE: MS. TANISHA NICOLA KELLY MS

MEDICARE: MS. TANISHA NICOLA KELLY MS
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1101YM0800XMental Health Counselor

General Provider Information

NPI Number : 1891951190
Entity Type Code : Individual
Provider Name (Legal Business Name) : MS. TANISHA NICOLA KELLY MS
Provider Business Mailing Address
First Line : 302 N JACKSON ST
Second Line :
City : STARKVILLE
State : MS
Zip : 39759-2504
Country : US
Telephone Number : 662-323-9261
Fax Number : 662-324-9647
Provider Business Practice Location Address
First Line : 507 W MAIN ST
Second Line :
City : LOUISVILLE
State : MS
Zip : 39339-2559
Country : US
Telephone Number : 662-773-9377
Fax Number : 662-773-9025
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/06/2008
Last Update Date : 09/10/2010

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