Healthcare Provider Details

I. General information

NPI: 1922643832
Provider Name (Legal Business Name): KELLI DENISE KERN RSW, MED
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KELLI DENISE CORLEY RSW

II. Dates (important events)

Enumeration Date: 11/14/2019
Last Update Date: 02/07/2020
Certification Date: 02/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 E MISSISSIPPI AVE # 900
RUSTON LA
71270-3905
US

IV. Provider business mailing address

1000 CHINABERRY DR STE 900
BOSSIER CITY LA
71111-2455
US

V. Phone/Fax

Practice location:
  • Phone: 318-202-3706
  • Fax: 318-202-3707
Mailing address:
  • Phone: 318-675-0804
  • Fax: 318-425-9030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number5018
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: