Provider Demographics
NPI:1558601047
Name:KELLY, KEENA (CASE MANAGER)
Entity Type:Individual
Prefix:MRS
First Name:KEENA
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:CASE MANAGER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4355 WEST 182ND PLACE
Mailing Address - Street 2:
Mailing Address - City:COUNTRY CLUB HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60478
Mailing Address - Country:US
Mailing Address - Phone:312-636-0116
Mailing Address - Fax:708-914-4012
Practice Address - Street 1:4355 WEST 182ND PLACE
Practice Address - Street 2:
Practice Address - City:COUNTRY CLUB HILLS
Practice Address - State:IL
Practice Address - Zip Code:60478
Practice Address - Country:US
Practice Address - Phone:312-636-0116
Practice Address - Fax:708-914-4012
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-21
Last Update Date:2013-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator