Provider Demographics
NPI:1235851726
Name:KELLY, HEATHER MARGARET
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:MARGARET
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 1:3387 S SANTA ROSA DR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84109-4132
Mailing Address - Country:US
Mailing Address - Phone:801-759-0020
Mailing Address - Fax:
Practice Address - Street 1:3387 S SANTA ROSA DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84109-4132
Practice Address - Country:US
Practice Address - Phone:801-759-0020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-13
Last Update Date:2022-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5904301-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical