Provider Demographics
NPI:1033593033
Name:MARCELLO, KELLEY (MED, LCMHC)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:
Last Name:MARCELLO
Suffix:
Gender:F
Credentials:MED, LCMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1695 E CONWAY RD
Mailing Address - Street 2:
Mailing Address - City:CENTER CONWAY
Mailing Address - State:NH
Mailing Address - Zip Code:03813-4018
Mailing Address - Country:US
Mailing Address - Phone:603-939-2040
Mailing Address - Fax:
Practice Address - Street 1:182 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:NH
Practice Address - Zip Code:03818-6140
Practice Address - Country:US
Practice Address - Phone:603-447-6356
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-20
Last Update Date:2015-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1118101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health