Healthcare Provider Details

I. General information

NPI: 1558111237
Provider Name (Legal Business Name): KELLIE M DEJAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2024
Last Update Date: 03/25/2024
Certification Date: 03/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 FAY WAY
SLIDELL LA
70460-3213
US

IV. Provider business mailing address

115 FAY WAY
SLIDELL LA
70460-3213
US

V. Phone/Fax

Practice location:
  • Phone: 504-812-5999
  • Fax:
Mailing address:
  • Phone: 504-812-5999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number5911
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: