Provider Demographics
NPI:1821263724
Name:KELLY, CARRIE L (LPC, SACIT)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:L
Last Name:KELLY
Suffix:
Gender:F
Credentials:LPC, SACIT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1005
Mailing Address - Street 2:
Mailing Address - City:ELKHORN
Mailing Address - State:WI
Mailing Address - Zip Code:53121-1005
Mailing Address - Country:US
Mailing Address - Phone:262-741-3200
Mailing Address - Fax:262-741-3217
Practice Address - Street 1:W4051 COUNTY ROAD NN
Practice Address - Street 2:
Practice Address - City:ELKHORN
Practice Address - State:WI
Practice Address - Zip Code:53121-4338
Practice Address - Country:US
Practice Address - Phone:262-741-3200
Practice Address - Fax:262-741-3217
Is Sole Proprietor?:No
Enumeration Date:2008-04-23
Last Update Date:2012-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4558-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1821263724Medicaid
KY30604011Medicaid