Provider Demographics
NPI:1710026372
Name:HAVILL, KELLEY (LMFT, LMHC)
Entity Type:Individual
Prefix:MRS
First Name:KELLEY
Middle Name:
Last Name:HAVILL
Suffix:
Gender:F
Credentials:LMFT, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3925 HAGAN ST
Mailing Address - Street 2:203
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-8556
Mailing Address - Country:US
Mailing Address - Phone:812-333-9895
Mailing Address - Fax:812-334-0001
Practice Address - Street 1:3925 HAGAN ST
Practice Address - Street 2:203
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401
Practice Address - Country:US
Practice Address - Phone:812-334-0001
Practice Address - Fax:812-334-0001
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39001493A101YM0800X
IN35001502A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health