Provider Demographics
NPI:1629550256
Name:KELLEY, CAROLYNE
Entity Type:Individual
Prefix:
First Name:CAROLYNE
Middle Name:
Last Name:KELLEY
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 1:8284 CLINTON WAY LN
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38018-6305
Mailing Address - Country:US
Mailing Address - Phone:190-128-3645
Mailing Address - Fax:901-666-8440
Practice Address - Street 1:6413 QUINCE RD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-8219
Practice Address - Country:US
Practice Address - Phone:901-690-5213
Practice Address - Fax:901-666-8440
Is Sole Proprietor?:No
Enumeration Date:2018-08-30
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician