Provider Demographics
NPI:1477269488
Name:KELLEY, KAITLIN (ED S)
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:
Last Name:KELLEY
Suffix:
Gender:F
Credentials:ED S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 COURT SQ
Mailing Address - Street 2:
Mailing Address - City:HARRISONBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22802-3701
Mailing Address - Country:US
Mailing Address - Phone:540-434-2752
Mailing Address - Fax:
Practice Address - Street 1:1 COURT SQ
Practice Address - Street 2:
Practice Address - City:HARRISONBURG
Practice Address - State:VA
Practice Address - Zip Code:22802-3701
Practice Address - Country:US
Practice Address - Phone:540-434-2752
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-24
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAPPS-0607916103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool