Provider Demographics
NPI:1417406893
Name:KELLY, CONSTANCE
Entity Type:Individual
Prefix:
First Name:CONSTANCE
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 1:3650 S EASTERN AVE STE 360
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89169-3345
Mailing Address - Country:US
Mailing Address - Phone:702-756-8987
Mailing Address - Fax:
Practice Address - Street 1:3650 S EASTERN AVE STE 360
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89169
Practice Address - Country:US
Practice Address - Phone:702-756-8987
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-27
Last Update Date:2021-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician