Provider Demographics
NPI:1063450377
Name:CLARK, KELLY J (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:J
Last Name:CLARK
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:PO BOX 86
Mailing Address - Street 2:
Mailing Address - City:GLENVIEW
Mailing Address - State:KY
Mailing Address - Zip Code:40025-0086
Mailing Address - Country:US
Mailing Address - Phone:502-333-0160
Mailing Address - Fax:
Practice Address - Street 1:3430 NEWBURG RD
Practice Address - Street 2:LOUISVILLE BEHAVIORAL SUITE 212
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40218-2497
Practice Address - Country:US
Practice Address - Phone:502-333-0160
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA816652084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry