Provider Demographics
NPI:1215307483
Name:MARSENGILL, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MARSENGILL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4403 1ST AVE SE STE 104
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52402-3221
Mailing Address - Country:US
Mailing Address - Phone:319-202-1509
Mailing Address - Fax:
Practice Address - Street 1:4403 1ST AVE SE STE 104
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52402-3221
Practice Address - Country:US
Practice Address - Phone:319-202-1509
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-01
Last Update Date:2015-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00026101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)