Provider Demographics
NPI:1578803359
Name:KELLY, CAROL ANN
Entity Type:Individual
Prefix:MS
First Name:CAROL
Middle Name:ANN
Last Name:KELLY
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 1:7171 BOWLING DR
Mailing Address - Street 2:300
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95823-2034
Mailing Address - Country:US
Mailing Address - Phone:916-875-0703
Mailing Address - Fax:
Practice Address - Street 1:7171 BOWLING DR
Practice Address - Street 2:300
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95823-2034
Practice Address - Country:US
Practice Address - Phone:916-875-0703
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-15
Last Update Date:2013-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA171M0000XOther171M0000X