Provider Demographics
NPI:1851865851
Name:KELLY, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
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 1:20400 COLONEL GLENN RD
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72210-5323
Mailing Address - Country:US
Mailing Address - Phone:501-821-5500
Mailing Address - Fax:501-821-5580
Practice Address - Street 1:20400 COLONEL GLENN RD
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72210-5323
Practice Address - Country:US
Practice Address - Phone:501-821-5500
Practice Address - Fax:501-821-5580
Is Sole Proprietor?:No
Enumeration Date:2019-01-14
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARP1803031101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional