Provider Demographics
NPI:1154117836
Name:BIRD, KELLIE
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:BIRD
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 1:4 AVIS AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81005-3102
Mailing Address - Country:US
Mailing Address - Phone:719-233-2434
Mailing Address - Fax:
Practice Address - Street 1:862 COOPER TRL
Practice Address - Street 2:
Practice Address - City:CANON CITY
Practice Address - State:CO
Practice Address - Zip Code:81212-0012
Practice Address - Country:US
Practice Address - Phone:719-233-2434
Practice Address - Fax:719-233-2434
Is Sole Proprietor?:No
Enumeration Date:2025-04-17
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health