Provider Demographics
NPI:1740654888
Name:KELLY, JOANNA (MA, LMFT, RPT)
Entity type:Individual
Prefix:MS
First Name:JOANNA
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:MA, LMFT, RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15360 18TH AVE N APT 1010
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55447-2473
Mailing Address - Country:US
Mailing Address - Phone:612-961-1015
Mailing Address - Fax:612-524-5563
Practice Address - Street 1:12805 HWY 55 STE 216
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55441-3859
Practice Address - Country:US
Practice Address - Phone:612-440-1450
Practice Address - Fax:612-524-5563
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-29
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3192106H00000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health