Provider Demographics
NPI:1477214575
Name:KELLY, CARLA JEAN (LPC, LLPC)
Entity type:Individual
Prefix:
First Name:CARLA
Middle Name:JEAN
Last Name:KELLY
Suffix:
Gender:F
Credentials:LPC, LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6752 PLEASANTVIEW DR
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-1004
Mailing Address - Country:US
Mailing Address - Phone:269-352-1857
Mailing Address - Fax:
Practice Address - Street 1:800 E MILHAM AVE
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49002-1490
Practice Address - Country:US
Practice Address - Phone:269-249-7179
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-02
Last Update Date:2022-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401004965101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional