Provider Demographics
NPI:1114973369
Name:KELLEY, MARY L
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:L
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:PO BOX 17277
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:41017-0277
Mailing Address - Country:US
Mailing Address - Phone:859-426-7800
Mailing Address - Fax:859-426-7804
Practice Address - Street 1:503 CENTRE VIEW BLVD
Practice Address - Street 2:
Practice Address - City:CRESTVIEW HILLS
Practice Address - State:KY
Practice Address - Zip Code:41017-3444
Practice Address - Country:US
Practice Address - Phone:859-426-7800
Practice Address - Fax:859-426-7804
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-26
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1203103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY610661458OtherTIN
KY610661458OtherTIN