Provider Demographics
NPI:1275620148
Name:GILLETTE, KELLY (LCP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:GILLETTE
Suffix:
Gender:M
Credentials:LCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3101 N MICHIGAN ST
Mailing Address - Street 2:
Mailing Address - City:PITTSBURG
Mailing Address - State:KS
Mailing Address - Zip Code:66762-2545
Mailing Address - Country:US
Mailing Address - Phone:620-231-5141
Mailing Address - Fax:620-231-9811
Practice Address - Street 1:911 E CENTENNIAL DR
Practice Address - Street 2:
Practice Address - City:PITTSBURG
Practice Address - State:KS
Practice Address - Zip Code:66762-6601
Practice Address - Country:US
Practice Address - Phone:620-231-5130
Practice Address - Fax:620-235-7101
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS310103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist