Provider Demographics
NPI:1831653252
Name:KELLEY, CAROLYN DARLENE (CRADC)
Entity Type:Individual
Prefix:MRS
First Name:CAROLYN
Middle Name:DARLENE
Last Name:KELLEY
Suffix:
Gender:F
Credentials:CRADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:760 S KINGSHIGHWAY ST
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63703-7630
Mailing Address - Country:US
Mailing Address - Phone:573-335-4333
Mailing Address - Fax:573-335-4345
Practice Address - Street 1:760 S KINGSHIGHWAY ST
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-7630
Practice Address - Country:US
Practice Address - Phone:573-335-4333
Practice Address - Fax:573-335-4345
Is Sole Proprietor?:No
Enumeration Date:2019-01-30
Last Update Date:2019-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2708101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)