Provider Demographics
NPI:1922153345
Name:KELLY, SHEILA EMERSON (MA)
Entity Type:Individual
Prefix:MS
First Name:SHEILA
Middle Name:EMERSON
Last Name:KELLY
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3738
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25337-3738
Mailing Address - Country:US
Mailing Address - Phone:304-343-3231
Mailing Address - Fax:
Practice Address - Street 1:1031 QUARRIER ST
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-2317
Practice Address - Country:US
Practice Address - Phone:304-343-3231
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV307103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0165473000Medicaid