Provider Demographics
NPI:1013367069
Name:KELLY, SEAN
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:
Last Name:KELLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:827 VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80904-1510
Mailing Address - Country:US
Mailing Address - Phone:719-464-3163
Mailing Address - Fax:
Practice Address - Street 1:4465 NORTHPARK DR STE 309
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80907-4238
Practice Address - Country:US
Practice Address - Phone:719-464-3163
Practice Address - Fax:719-452-3713
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-20
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3110103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical