Provider Demographics
NPI:1619432275
Name:DORRIS, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:DORRIS
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 1:5115 WILLIAMS PL
Mailing Address - Street 2:
Mailing Address - City:GODFREY
Mailing Address - State:IL
Mailing Address - Zip Code:62035-1175
Mailing Address - Country:US
Mailing Address - Phone:618-979-1088
Mailing Address - Fax:
Practice Address - Street 1:645 BERKSHIRE BLVD
Practice Address - Street 2:
Practice Address - City:EAST ALTON
Practice Address - State:IL
Practice Address - Zip Code:62024-1324
Practice Address - Country:US
Practice Address - Phone:618-258-8750
Practice Address - Fax:618-258-8751
Is Sole Proprietor?:No
Enumeration Date:2019-02-07
Last Update Date:2019-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health