Healthcare Provider Details

I. General information

NPI: 1487246757
Provider Name (Legal Business Name): KELLIE PEBBLES LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2021
Last Update Date: 03/16/2021
Certification Date: 03/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

457 2ND ST
COLFAX LA
71417-1807
US

IV. Provider business mailing address

PO BOX 13312
ALEXANDRIA LA
71315-3312
US

V. Phone/Fax

Practice location:
  • Phone: 318-827-4357
  • Fax: 318-409-0099
Mailing address:
  • Phone: 318-827-4357
  • Fax: 318-409-0099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number15289
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: