Provider Demographics
NPI:1083167738
Name:KELLY, MEGAN M
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:M
Last Name:KELLY
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 1:88 S PARK AVE
Mailing Address - Street 2:
Mailing Address - City:LE CENTER
Mailing Address - State:MN
Mailing Address - Zip Code:56057-1658
Mailing Address - Country:US
Mailing Address - Phone:507-357-8504
Mailing Address - Fax:507-357-6122
Practice Address - Street 1:88 S PARK AVE
Practice Address - Street 2:
Practice Address - City:LE CENTER
Practice Address - State:MN
Practice Address - Zip Code:56057-1658
Practice Address - Country:US
Practice Address - Phone:507-357-8504
Practice Address - Fax:507-357-6122
Is Sole Proprietor?:No
Enumeration Date:2016-07-29
Last Update Date:2016-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker