Provider Demographics
NPI:1740946904
Name:KELLEY, BETHANY A (MED, LPA)
Entity type:Individual
Prefix:
First Name:BETHANY
Middle Name:A
Last Name:KELLEY
Suffix:
Gender:F
Credentials:MED, LPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:591 BEECH GROVE RD
Mailing Address - Street 2:
Mailing Address - City:SHEPHERDSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40165-6483
Mailing Address - Country:US
Mailing Address - Phone:502-468-2123
Mailing Address - Fax:
Practice Address - Street 1:6500 GLENRIDGE PARK PL STE 3
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222-3450
Practice Address - Country:US
Practice Address - Phone:502-614-7600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-11
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY288702103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY288702OtherLICENSING NUMBER (LPA)