Provider Demographics
NPI:1609490994
Name:CARL, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:CARL
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 1:1509 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18505-2707
Mailing Address - Country:US
Mailing Address - Phone:570-342-8305
Mailing Address - Fax:
Practice Address - Street 1:1509 MAPLE ST
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18505-2707
Practice Address - Country:US
Practice Address - Phone:570-342-8305
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-02
Last Update Date:2020-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst