Provider Demographics
NPI:1821305525
Name:KELLY, KATHLEEN ANN
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:ANN
Last Name:KELLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3042 DOLLSBERRY LN
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47448-8228
Mailing Address - Country:US
Mailing Address - Phone:812-219-6206
Mailing Address - Fax:
Practice Address - Street 1:517 N WALNUT ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47404-3845
Practice Address - Country:US
Practice Address - Phone:812-219-6202
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-02
Last Update Date:2016-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34006805A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical