Provider Demographics
NPI:1003624438
Name:KELLY, ALIVIA CATHERINE
Entity type:Individual
Prefix:
First Name:ALIVIA
Middle Name:CATHERINE
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 1:2385 ARIEL ST N
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:55109-2248
Mailing Address - Country:US
Mailing Address - Phone:651-338-9974
Mailing Address - Fax:
Practice Address - Street 1:2385 ARIEL ST N
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-2248
Practice Address - Country:US
Practice Address - Phone:651-338-9974
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-18
Last Update Date:2024-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician