Provider Demographics
NPI:1609210442
Name:KELLY, MELISSA KAYE (LAC)
Entity Type:Individual
Prefix:MS
First Name:MELISSA
Middle Name:KAYE
Last Name:KELLY
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2020 CHARLOTTE ST STE 4
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59718-2774
Mailing Address - Country:US
Mailing Address - Phone:406-209-8397
Mailing Address - Fax:
Practice Address - Street 1:2020 CHARLOTTE ST STE 4
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59718-2774
Practice Address - Country:US
Practice Address - Phone:406-209-8397
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-23
Last Update Date:2013-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1005101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)