Provider Demographics
NPI:1437347838
Name:KELLY, JOANNE B (PSYD)
Entity Type:Individual
Prefix:
First Name:JOANNE
Middle Name:B
Last Name:KELLY
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5601 S. COUNTY LINE ROAD
Mailing Address - Street 2:
Mailing Address - City:HINSDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60521-4875
Mailing Address - Country:US
Mailing Address - Phone:630-286-0422
Mailing Address - Fax:630-286-4247
Practice Address - Street 1:5601 S COUNTY LINE RD
Practice Address - Street 2:
Practice Address - City:HINSDALE
Practice Address - State:IL
Practice Address - Zip Code:60521-4875
Practice Address - Country:US
Practice Address - Phone:630-286-0422
Practice Address - Fax:630-286-4247
Is Sole Proprietor?:No
Enumeration Date:2007-10-10
Last Update Date:2007-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK16191Medicare UPIN