Provider Demographics
NPI:1720761240
Name:FITZPATRICK, KELLY CONLEY (RDH BSDH)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:CONLEY
Last Name:FITZPATRICK
Suffix:
Gender:F
Credentials:RDH BSDH
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:MCVEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDH BSDH
Mailing Address - Street 1:711 W MORELAND BLVD STE 204
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-2483
Mailing Address - Country:US
Mailing Address - Phone:262-896-9891
Mailing Address - Fax:
Practice Address - Street 1:711 W MORELAND BLVD STE 204
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-2483
Practice Address - Country:US
Practice Address - Phone:262-896-9891
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-10
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1002571-16101200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101200000XBehavioral Health & Social Service ProvidersDrama Therapist