Provider Demographics
NPI:1629497094
Name:KELLY ANGLIN LLC
Entity Type:Organization
Organization Name:KELLY ANGLIN LLC
Other - Org Name:ANGLIN FAMILY THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:LMFT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:DARLENE
Authorized Official - Last Name:ANGLIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-608-7398
Mailing Address - Street 1:8205 SPAIN RD NE
Mailing Address - Street 2:SUITE 106
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-3179
Mailing Address - Country:US
Mailing Address - Phone:505-384-7352
Mailing Address - Fax:505-274-7338
Practice Address - Street 1:3300 N BUTLER AVE
Practice Address - Street 2:SUITE 217
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-5621
Practice Address - Country:US
Practice Address - Phone:505-608-7398
Practice Address - Fax:505-634-7044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-14
Last Update Date:2014-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0162711106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty