Provider Demographics
NPI:1629281530
Name:KELLY, MICHAEL CASHMAN (MS - LP)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:CASHMAN
Last Name:KELLY
Suffix:
Gender:M
Credentials:MS - LP
Other - Prefix:MR
Other - First Name:MICHAEL
Other - Middle Name:PATRICK
Other - Last Name:KELLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NONE
Mailing Address - Street 1:3600 W SAINT GERMAIN ST APT 256
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56301-4639
Mailing Address - Country:US
Mailing Address - Phone:320-230-0191
Mailing Address - Fax:
Practice Address - Street 1:2025 STEARNS WAY
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-4491
Practice Address - Country:US
Practice Address - Phone:320-229-1500
Practice Address - Fax:320-229-1505
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP 4136103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN517402OtherVALUE OPTIONS
MN62 - 64674OtherUNITED BEHAVIORAL HEALTH
MN00189405OtherEMPLOYEE ID FOR STATE OF
MN422T6KEOtherBLUE CROSS- BLUE SHIELD
MN00189405OtherMN EMPLOYEE ID NUMBER
MN13H51876KEOtherB.H.S.I.