Provider Demographics
NPI:1457414773
Name:KELLEY, KATHRYN A (LPC)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:A
Last Name:KELLEY
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4120 E CALLE MARFIL
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-6409
Mailing Address - Country:US
Mailing Address - Phone:520-490-9698
Mailing Address - Fax:406-227-6790
Practice Address - Street 1:1661 N SWAN RD STE 102
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-4051
Practice Address - Country:US
Practice Address - Phone:520-490-9698
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-2503101Y00000X, 101YP2500X, 101YM0800X
MT1221-LCPC101YP2500X
AZCC 2503101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT742650OtherBCBSMT PROVIDER NUMBER