Provider Demographics
NPI:1235382128
Name:DARDEEN, KELLY RENEE (PHD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:RENEE
Last Name:DARDEEN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1241 CUMBERLAND AVE
Mailing Address - Street 2:
Mailing Address - City:WEST LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47906-1304
Mailing Address - Country:US
Mailing Address - Phone:812-629-4999
Mailing Address - Fax:765-607-1483
Practice Address - Street 1:1241 CUMBERLAND AVE
Practice Address - Street 2:
Practice Address - City:WEST LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47906-1304
Practice Address - Country:US
Practice Address - Phone:812-629-4999
Practice Address - Fax:765-607-1483
Is Sole Proprietor?:No
Enumeration Date:2008-10-23
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20042319A103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000001056306OtherANTHEM PROVIDER NUMBER
IN000001056306OtherANTHEM PROVIDER NUMBER
INM400016760Medicare PIN
IN200957090Medicaid
INM400016761Medicare PIN