Provider Demographics
NPI:1003877895
Name:KELLY, SUSAN E (PHD, LMHC)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:E
Last Name:KELLY
Suffix:
Gender:F
Credentials:PHD, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1824
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52406-1824
Mailing Address - Country:US
Mailing Address - Phone:319-369-4505
Mailing Address - Fax:319-369-4677
Practice Address - Street 1:5264 COUNCIL ST NE
Practice Address - Street 2:STE 400
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52402-2471
Practice Address - Country:US
Practice Address - Phone:319-398-6694
Practice Address - Fax:319-369-4673
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00408101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor