Provider Demographics
NPI:1689763849
Name:ORR, KELLY KENT (PHD, ABPP)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:KENT
Last Name:ORR
Suffix:
Gender:M
Credentials:PHD, ABPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2155 HOLLOW BROOK DR
Mailing Address - Street 2:SUITE 70
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918-1451
Mailing Address - Country:US
Mailing Address - Phone:719-266-5244
Mailing Address - Fax:719-266-5245
Practice Address - Street 1:2155 HOLLOW BROOK DR
Practice Address - Street 2:SUITE 70
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-1451
Practice Address - Country:US
Practice Address - Phone:719-266-5244
Practice Address - Fax:719-266-5245
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2010-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA776103TC0700X
CO2706103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO30634717Medicaid
800616Medicare ID - Type Unspecified