Provider Demographics
NPI:1093871717
Name:KELLY, JOSEPH B (LPC)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:B
Last Name:KELLY
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 45
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368-0045
Mailing Address - Country:US
Mailing Address - Phone:219-787-1510
Mailing Address - Fax:219-787-8761
Practice Address - Street 1:3600 VETERANS DR
Practice Address - Street 2:SUITE 3
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-4582
Practice Address - Country:US
Practice Address - Phone:231-933-4009
Practice Address - Fax:231-933-4032
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2009-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401005316101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor