Healthcare Provider Details

I. General information

NPI: 1740853407
Provider Name (Legal Business Name): DESTINY D KELLY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2021
Last Update Date: 12/02/2025
Certification Date: 12/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9403 MANSFIELD RD
SHREVEPORT LA
71118-3815
US

IV. Provider business mailing address

800 SPRING ST
SHREVEPORT LA
71101-3758
US

V. Phone/Fax

Practice location:
  • Phone: 318-861-8938
  • Fax:
Mailing address:
  • Phone: 318-670-3170
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: