Provider Demographics
NPI:1962039362
Name:KELLY, DELTA
Entity Type:Individual
Prefix:
First Name:DELTA
Middle Name:
Last Name:KELLY
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 1:2000 BERRY CHASE PL
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36117-6896
Mailing Address - Country:US
Mailing Address - Phone:334-669-1944
Mailing Address - Fax:
Practice Address - Street 1:2000 BERRY CHASE PL
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36117-6896
Practice Address - Country:US
Practice Address - Phone:334-669-1944
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-25
Last Update Date:2020-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALC3262A101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor