Provider Demographics
NPI:1427190040
Name:SHADA, KELLY JO (RN,LMHP)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:JO
Last Name:SHADA
Suffix:
Gender:F
Credentials:RN,LMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5205 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:KEARNEY
Mailing Address - State:NE
Mailing Address - Zip Code:68847-2471
Mailing Address - Country:US
Mailing Address - Phone:308-236-7545
Mailing Address - Fax:308-236-7545
Practice Address - Street 1:5205 2ND AVE
Practice Address - Street 2:
Practice Address - City:KEARNEY
Practice Address - State:NE
Practice Address - Zip Code:68847-2471
Practice Address - Country:US
Practice Address - Phone:308-236-7545
Practice Address - Fax:308-236-7545
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE423101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE84306OtherBLUE CROSS BLUE SHIELD
NE25690OtherMIDLANDS CHOICE