Provider Demographics
NPI:1255665055
Name:KING, KELLY J (MA)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:J
Last Name:KING
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 1:5600 S 59TH ST STE 104
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68516-2387
Mailing Address - Country:US
Mailing Address - Phone:402-484-0595
Mailing Address - Fax:402-484-6306
Practice Address - Street 1:5600 S 59TH ST STE 104
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68516-2387
Practice Address - Country:US
Practice Address - Phone:402-484-0595
Practice Address - Fax:402-484-6306
Is Sole Proprietor?:No
Enumeration Date:2009-09-25
Last Update Date:2013-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE4152101YM0800X
NE967101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE96118OtherBCBS
NE96118OtherBCBS