Provider Demographics
NPI:1942089164
Name:COULOPOULOS, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:COULOPOULOS
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 1:1336 LAKE CHARLES AVE
Mailing Address - Street 2:
Mailing Address - City:CHESTERTON
Mailing Address - State:IN
Mailing Address - Zip Code:46304-9763
Mailing Address - Country:US
Mailing Address - Phone:219-816-1590
Mailing Address - Fax:
Practice Address - Street 1:402 WALL ST STE 42
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-2572
Practice Address - Country:US
Practice Address - Phone:219-510-8043
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-26
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34009747A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical