Provider Demographics
NPI:1497198691
Name:MCINTYRE, KELLLIE JO
Entity Type:Individual
Prefix:MISS
First Name:KELLLIE
Middle Name:JO
Last Name:MCINTYRE
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 1:750 N 200 E
Mailing Address - Street 2:SUITE 300
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84606-1705
Mailing Address - Country:US
Mailing Address - Phone:801-373-4760
Mailing Address - Fax:
Practice Address - Street 1:750 NORTH 200 WEST
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601
Practice Address - Country:US
Practice Address - Phone:801-373-4760
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-08
Last Update Date:2013-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist