Provider Demographics
NPI:1003293838
Name:DEMOS KELLEY, SANDRA (LCPC)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:DEMOS KELLEY
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8300 BROADWAY
Mailing Address - Street 2:F1
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-8602
Mailing Address - Country:US
Mailing Address - Phone:219-736-1000
Mailing Address - Fax:219-736-9699
Practice Address - Street 1:8300 BROADWAY
Practice Address - Street 2:F1
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-8602
Practice Address - Country:US
Practice Address - Phone:219-736-1000
Practice Address - Fax:219-736-9699
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-30
Last Update Date:2015-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1800004640101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional