Provider Demographics
NPI:1891392890
Name:CONNER, KELLY CARLTON
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:CARLTON
Last Name:CONNER
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 1:3101 MAGIC HOLLOW BLVD
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23453-3010
Mailing Address - Country:US
Mailing Address - Phone:757-639-2218
Mailing Address - Fax:866-594-3899
Practice Address - Street 1:509 OLD GREAT NECK RD STE 203
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-3358
Practice Address - Country:US
Practice Address - Phone:757-520-1312
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-03
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VARBT-20-137898106S00000X
VA0704015413101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician