=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073530903
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KELLY LINER DEROUEN, LPC-S, LMFT, NCC, NCSC, SUPERVISOR LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/16/2006
-----------------------------------------------------
Last Update Date | 11/24/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 547 BAYOU DULARGE ROAD
-----------------------------------------------------
City | HOUMA
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70363
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 985-876-5748
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 547 BAYOU DULARGE ROAD
-----------------------------------------------------
City | HOUMA
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70363
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 985-876-5748
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COUNSELOR
-----------------------------------------------------
Name | MS. KELLY LINER DEROUEN
-----------------------------------------------------
Credential | LPC-S,LMFT,NCC,NCSC,
-----------------------------------------------------
Telephone | 985-876-5748
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YS0200X
-----------------------------------------------------
Taxonomy Name | School Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------