Healthcare Provider Details

I. General information

NPI: 1609173533
Provider Name (Legal Business Name): LURETHA KELLY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/11/2011
Last Update Date: 08/23/2024
Certification Date: 08/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 STONE CV
CLINTON MS
39056-5020
US

IV. Provider business mailing address

114 STONE CV
CLINTON MS
39056-5020
US

V. Phone/Fax

Practice location:
  • Phone: 601-572-4268
  • Fax: 601-885-6028
Mailing address:
  • Phone: 601-572-4268
  • Fax: 601-885-6028

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC6936
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC6936
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberM6936
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: