Provider Demographics
NPI:1134995582
Name:STANLEY, KELLEY MICHELE
Entity type:Individual
Prefix:
First Name:KELLEY
Middle Name:MICHELE
Last Name:STANLEY
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:PO BOX 272
Mailing Address - Street 2:
Mailing Address - City:GALLIPOLIS
Mailing Address - State:OH
Mailing Address - Zip Code:45631-0272
Mailing Address - Country:US
Mailing Address - Phone:740-441-5809
Mailing Address - Fax:740-578-9242
Practice Address - Street 1:49 OLIVE ST
Practice Address - Street 2:
Practice Address - City:GALLIPOLIS
Practice Address - State:OH
Practice Address - Zip Code:45631-1632
Practice Address - Country:US
Practice Address - Phone:740-441-5809
Practice Address - Fax:740-578-9242
Is Sole Proprietor?:No
Enumeration Date:2023-11-28
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
OHCDCA.187974101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician