Provider Demographics
NPI:1134417132
Name:FELLER, KELLY CARL (PHD, LCSW)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:CARL
Last Name:FELLER
Suffix:
Gender:M
Credentials:PHD, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1048 E FAIRWAY DR
Mailing Address - Street 2:
Mailing Address - City:NORTH SALT LAKE
Mailing Address - State:UT
Mailing Address - Zip Code:84054-3056
Mailing Address - Country:US
Mailing Address - Phone:801-809-1049
Mailing Address - Fax:
Practice Address - Street 1:537 W 2600 S
Practice Address - Street 2:SUITE 203
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-7779
Practice Address - Country:US
Practice Address - Phone:801-809-1049
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-12
Last Update Date:2011-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7057775-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical