Provider Demographics
NPI:1154452969
Name:BAIN-CONKIN, KELLY E (MS, LMHC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:E
Last Name:BAIN-CONKIN
Suffix:
Gender:F
Credentials:MS, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 N MICHIGAN ST
Mailing Address - Street 2:SUITE 208
Mailing Address - City:PLYMOUTH
Mailing Address - State:IN
Mailing Address - Zip Code:46563-1770
Mailing Address - Country:US
Mailing Address - Phone:574-935-9449
Mailing Address - Fax:574-935-3956
Practice Address - Street 1:310 N MICHIGAN ST
Practice Address - Street 2:SUITE 208
Practice Address - City:PLYMOUTH
Practice Address - State:IN
Practice Address - Zip Code:46563-1770
Practice Address - Country:US
Practice Address - Phone:574-935-9449
Practice Address - Fax:574-935-3956
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2010-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
IN39002134A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor