Provider Demographics
NPI:1972607562
Name:KELLY, THOMAS E (PSYD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:E
Last Name:KELLY
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2399 ARIEL ST N
Mailing Address - Street 2:SUITE D
Mailing Address - City:MAPLEWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:55109-2203
Mailing Address - Country:US
Mailing Address - Phone:651-770-1311
Mailing Address - Fax:651-770-1879
Practice Address - Street 1:108 S MINNESOTA AVE STE 102
Practice Address - Street 2:
Practice Address - City:SAINT PETER
Practice Address - State:MN
Practice Address - Zip Code:56082-2557
Practice Address - Country:US
Practice Address - Phone:507-484-2400
Practice Address - Fax:507-934-5220
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-12
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3386-125101YP2500X
IA00871101YP2500X
MN00018101YP2500X
IL180-003674101YP2500X
MNLP5043103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1972607562Medicaid