Provider Demographics
NPI:1295543734
Name:COUNTS, KELLY JO
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:JO
Last Name:COUNTS
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 1:4501 ATKINS LN
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47725-8973
Mailing Address - Country:US
Mailing Address - Phone:812-589-7343
Mailing Address - Fax:
Practice Address - Street 1:1112 S MAIN ST
Practice Address - Street 2:
Practice Address - City:HUNTINGBURG
Practice Address - State:IN
Practice Address - Zip Code:47542-9164
Practice Address - Country:US
Practice Address - Phone:812-589-7343
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-30
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician