Provider Demographics
NPI:1619938800
Name:DANIEL, KELLY R (MA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:R
Last Name:DANIEL
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 20TH ST
Mailing Address - Street 2:SUITE 205
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25703-2071
Mailing Address - Country:US
Mailing Address - Phone:304-691-1500
Mailing Address - Fax:304-523-4358
Practice Address - Street 1:1115 20TH ST
Practice Address - Street 2:SUITE 205
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25703-2071
Practice Address - Country:US
Practice Address - Phone:304-691-1500
Practice Address - Fax:304-523-4358
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2012-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV809103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV9202134000Medicaid
OH2372212Medicaid
WV9202134000Medicaid