Healthcare Provider Details

I. General information

NPI: 1437159639
Provider Name (Legal Business Name): KELLY PAULK RAY PHD, MP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2005
Last Update Date: 02/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7913 WRENWOOD BLVD STE A
BATON ROUGE LA
70809
US

IV. Provider business mailing address

7913 WRENWOOD BLVD STE A
BATON ROUGE LA
70809-1793
US

V. Phone/Fax

Practice location:
  • Phone: 225-763-6300
  • Fax: 225-763-9358
Mailing address:
  • Phone: 225-763-6300
  • Fax: 225-763-9358

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License NumberMP.0862
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: