Provider Demographics
NPI:1689297285
Name:MICHLENA, KELLY KAY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:KAY
Last Name:MICHLENA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:KAY
Other - Last Name:KULISH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:245 W RACE ST
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:PA
Mailing Address - Zip Code:15501-1922
Mailing Address - Country:US
Mailing Address - Phone:814-443-4891
Mailing Address - Fax:
Practice Address - Street 1:245 W RACE ST
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:PA
Practice Address - Zip Code:15501-1922
Practice Address - Country:US
Practice Address - Phone:814-443-4891
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-19
Last Update Date:2020-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PABH004627101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor