Provider Demographics
NPI:1477627560
Name:HARTZ, KELLY MICHAEL (MED)
Entity Type:Individual
Prefix:MR
First Name:KELLY
Middle Name:MICHAEL
Last Name:HARTZ
Suffix:
Gender:M
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 MAPLE
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101
Mailing Address - Country:US
Mailing Address - Phone:505-769-9128
Mailing Address - Fax:
Practice Address - Street 1:1100 W 21ST
Practice Address - Street 2:MENTAL HEALTH RESOURCES
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101
Practice Address - Country:US
Practice Address - Phone:505-769-2345
Practice Address - Fax:505-769-8974
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator