Provider Demographics
NPI:1851895031
Name:KELLY, PATRICK HARRY (MA, LPC)
Entity Type:Individual
Prefix:MR
First Name:PATRICK
Middle Name:HARRY
Last Name:KELLY
Suffix:
Gender:M
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11008 MICHIGAN DR.
Mailing Address - Street 2:
Mailing Address - City:SPRING GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60081-8491
Mailing Address - Country:US
Mailing Address - Phone:815-322-3942
Mailing Address - Fax:
Practice Address - Street 1:5435 BULL VALLEY RD STE 230
Practice Address - Street 2:
Practice Address - City:MCHENRY
Practice Address - State:IL
Practice Address - Zip Code:60050-7435
Practice Address - Country:US
Practice Address - Phone:847-438-4222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-21
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.013436101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health