Provider Demographics
NPI:1053073544
Name:KELLEY, ALLY MARIE
Entity Type:Individual
Prefix:
First Name:ALLY
Middle Name:MARIE
Last Name:KELLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:504 11TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:KASSON
Mailing Address - State:MN
Mailing Address - Zip Code:55944-2060
Mailing Address - Country:US
Mailing Address - Phone:507-226-5982
Mailing Address - Fax:
Practice Address - Street 1:124 ELTON HILLS LN NW
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55901-3577
Practice Address - Country:US
Practice Address - Phone:507-282-1009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-12
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician