Healthcare Provider Details

I. General information

NPI: 1073530903
Provider Name (Legal Business Name): KELLY LINER DEROUEN, LPC-S, LMFT, NCC, NCSC, SUPERVISOR LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2006
Last Update Date: 11/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

547 BAYOU DULARGE ROAD
HOUMA LA
70363
US

IV. Provider business mailing address

547 BAYOU DULARGE ROAD
HOUMA LA
70363
US

V. Phone/Fax

Practice location:
  • Phone: 985-876-5748
  • Fax:
Mailing address:
  • Phone: 985-876-5748
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: MS. KELLY LINER DEROUEN
Title or Position: COUNSELOR
Credential: LPC-S,LMFT,NCC,NCSC,
Phone: 985-876-5748