Provider Demographics
NPI:1790037794
Name:KELLEY, THOMAS LEO
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:LEO
Last Name:KELLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2947 THINNES ST
Mailing Address - Street 2:
Mailing Address - City:CROSS PLAINS
Mailing Address - State:WI
Mailing Address - Zip Code:53528-9540
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2947 THINNES ST
Practice Address - Street 2:
Practice Address - City:CROSS PLAINS
Practice Address - State:WI
Practice Address - Zip Code:53528-9540
Practice Address - Country:US
Practice Address - Phone:608-576-6151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-15
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI268-228106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist