Provider Demographics
NPI:1619113842
Name:EARL, KELLY KATHLEEN (CACII)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:KATHLEEN
Last Name:EARL
Suffix:
Gender:F
Credentials:CACII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 E 13TH ST
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81001-2940
Mailing Address - Country:US
Mailing Address - Phone:719-546-6666
Mailing Address - Fax:
Practice Address - Street 1:509 E 13TH ST
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81001-2940
Practice Address - Country:US
Practice Address - Phone:719-546-6666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-17
Last Update Date:2008-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO4887101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)