Provider Demographics
NPI:1497302400
Name:KELLS, GINA C
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:C
Last Name:KELLS
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 1:190 CHERRY HILL DR
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:VA
Mailing Address - Zip Code:22556-3654
Mailing Address - Country:US
Mailing Address - Phone:616-425-1016
Mailing Address - Fax:
Practice Address - Street 1:190 CHERRY HILL DR
Practice Address - Street 2:
Practice Address - City:STAFFORD
Practice Address - State:VA
Practice Address - Zip Code:22556-3654
Practice Address - Country:US
Practice Address - Phone:616-425-1016
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-23
Last Update Date:2019-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician