Provider Demographics
NPI:1417654237
Name:KELLY, AMANDA KAY
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:KAY
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 1:128 CRESTVIEW DR
Mailing Address - Street 2:
Mailing Address - City:BRANDENBURG
Mailing Address - State:KY
Mailing Address - Zip Code:40108-1216
Mailing Address - Country:US
Mailing Address - Phone:270-945-5099
Mailing Address - Fax:
Practice Address - Street 1:298 MEDLEY CT
Practice Address - Street 2:
Practice Address - City:VINE GROVE
Practice Address - State:KY
Practice Address - Zip Code:40175-8421
Practice Address - Country:US
Practice Address - Phone:270-352-1133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-13
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY23-256142106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty