Provider Demographics
NPI:1639128119
Name:MCGRAW, KELLY L (PSYD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:L
Last Name:MCGRAW
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9700 PARK PLAZA AVE
Mailing Address - Street 2:SUITE 106
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40241-2236
Mailing Address - Country:US
Mailing Address - Phone:502-429-5431
Mailing Address - Fax:502-429-5495
Practice Address - Street 1:9700 PARK PLAZA AVE
Practice Address - Street 2:SUITE 106
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40241-2236
Practice Address - Country:US
Practice Address - Phone:502-429-5431
Practice Address - Fax:502-429-5495
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6046103T00000X
KY1322103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000490468OtherANTHEM BCBS