Provider Demographics
NPI:1295474344
Name:LEADER, KELLY DENISSE (LAC)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:DENISSE
Last Name:LEADER
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:DENISSE
Other - Last Name:LEADER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LAC
Mailing Address - Street 1:1501 S WALDRON RD STE 100
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903-2568
Mailing Address - Country:US
Mailing Address - Phone:479-259-3969
Mailing Address - Fax:
Practice Address - Street 1:1501 S WALDRON RD STE 100
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-2568
Practice Address - Country:US
Practice Address - Phone:479-561-7600
Practice Address - Fax:479-434-4333
Is Sole Proprietor?:No
Enumeration Date:2022-05-27
Last Update Date:2022-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA2106018101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional