Provider Demographics
NPI:1225445018
Name:KELLY, LYDIA
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:
Last Name:KELLY
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 1:307 NAPLES DR
Mailing Address - Street 2:
Mailing Address - City:RANTOUL
Mailing Address - State:IL
Mailing Address - Zip Code:61866-3463
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:801 N WALNUT ST
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-3055
Practice Address - Country:US
Practice Address - Phone:217-373-2430
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-14
Last Update Date:2014-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker