Provider Demographics
NPI:1164542585
Name:BISHOP, KELLI M (PSYD)
Entity Type:Individual
Prefix:DR
First Name:KELLI
Middle Name:M
Last Name:BISHOP
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:4255 WADE GREEN RD NW
Mailing Address - Street 2:STE 414
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-1763
Mailing Address - Country:US
Mailing Address - Phone:678-213-2194
Mailing Address - Fax:678-922-7767
Practice Address - Street 1:111 E 16TH ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-5919
Practice Address - Country:US
Practice Address - Phone:208-523-1130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2016-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPSY-202640103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical