Provider Demographics
NPI:1942666318
Name:KELLY, CHRISTIE LYNN (T-LPC)
Entity Type:Individual
Prefix:
First Name:CHRISTIE
Middle Name:LYNN
Last Name:KELLY
Suffix:
Gender:F
Credentials:T-LPC
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 1223
Mailing Address - Street 2:
Mailing Address - City:GREAT BEND
Mailing Address - State:KS
Mailing Address - Zip Code:67530-1223
Mailing Address - Country:US
Mailing Address - Phone:620-796-2206
Mailing Address - Fax:866-288-1782
Practice Address - Street 1:809 S PATTON RD
Practice Address - Street 2:
Practice Address - City:GREAT BEND
Practice Address - State:KS
Practice Address - Zip Code:67530-4620
Practice Address - Country:US
Practice Address - Phone:620-796-2206
Practice Address - Fax:866-288-1782
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-14
Last Update Date:2019-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 101YM0800X
KS703101YA0400X
KS2755101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS201137740CMedicaid