Provider Demographics
NPI:1225377120
Name:HALTER, KELLEY (MA)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:
Last Name:HALTER
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1108 34TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58701-7250
Mailing Address - Country:US
Mailing Address - Phone:701-818-9223
Mailing Address - Fax:
Practice Address - Street 1:20 1ST ST SW STE 250
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58701-3851
Practice Address - Country:US
Practice Address - Phone:701-852-3328
Practice Address - Fax:701-838-2521
Is Sole Proprietor?:No
Enumeration Date:2013-02-12
Last Update Date:2015-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND809-11-15-14101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional