Provider Demographics
NPI:1225382294
Name:KELLEY, ELISA AMY
Entity Type:Individual
Prefix:
First Name:ELISA
Middle Name:AMY
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 1:623 DAHL RD
Mailing Address - Street 2:
Mailing Address - City:SPEARFISH
Mailing Address - State:SD
Mailing Address - Zip Code:57783-2782
Mailing Address - Country:US
Mailing Address - Phone:605-642-2777
Mailing Address - Fax:
Practice Address - Street 1:350 ELK ST
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-7351
Practice Address - Country:US
Practice Address - Phone:605-642-2777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-30
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor