Provider Demographics
NPI:1891165635
Name:KELLEY, ELIZABETH (CSAC)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:KELLEY
Suffix:
Gender:F
Credentials:CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2640 W POINT RD
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54304-1344
Mailing Address - Country:US
Mailing Address - Phone:920-490-3701
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 365
Practice Address - Street 2:
Practice Address - City:ONEIDA
Practice Address - State:WI
Practice Address - Zip Code:54155-0365
Practice Address - Country:US
Practice Address - Phone:920-490-3799
Practice Address - Fax:920-490-3799
Is Sole Proprietor?:No
Enumeration Date:2015-10-06
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WINO.16035-131101YA0400X
WINO.16035-132101YA0400X
WINO.7485-226101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)