Provider Demographics
NPI:1609173533
Name:KELLY, LURETHA (LCSW)
Entity type:Individual
Prefix:
First Name:LURETHA
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 STONE CV
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MS
Mailing Address - Zip Code:39056-5020
Mailing Address - Country:US
Mailing Address - Phone:601-572-4268
Mailing Address - Fax:601-885-6028
Practice Address - Street 1:114 STONE CV
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MS
Practice Address - Zip Code:39056-5020
Practice Address - Country:US
Practice Address - Phone:601-572-4268
Practice Address - Fax:601-885-6028
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-11
Last Update Date:2024-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC69361041C0700X, 101YM0800X
MSM6936104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08434862Medicaid