Provider Demographics
NPI:1831497114
Name:KELLY, YEZLIN DENAE (SAC-IT)
Entity Type:Individual
Prefix:
First Name:YEZLIN
Middle Name:DENAE
Last Name:KELLY
Suffix:
Gender:F
Credentials:SAC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3530 N 11TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53206-3031
Mailing Address - Country:US
Mailing Address - Phone:414-344-3406
Mailing Address - Fax:
Practice Address - Street 1:230 W WELLS ST STE 312
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53203-1837
Practice Address - Country:US
Practice Address - Phone:414-344-3406
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-10
Last Update Date:2011-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15839-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)