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General NPI Number Information
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NPI Number | 1669818985
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Entity Type | Individual
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Provider Name | KELLY M TYNER PH.D.
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Gender | Female
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Dates
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Enumeration Date | 05/14/2013
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Last Update Date | 05/14/2013
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Provider Practice Location Address
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Address Line | 820 JORDAN ST SUITE 570
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City | SHREVEPORT
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State | LA
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Zip | 71101-4518
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Country | US
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Telephone | 318-415-9437
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Fax |
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Provider Business Mailing Address
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Address Line | 9369 DELORES DR
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City | SHREVEPORT
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State | LA
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Zip | 71118-3304
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Country | US
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Telephone | 318-415-9437
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | MFT1163
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License Number State | LA
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