Provider Demographics
NPI:1750363263
Name:KELLY, KIMBERLEY S (LMHC, LMSW, IADC)
Entity type:Individual
Prefix:
First Name:KIMBERLEY
Middle Name:S
Last Name:KELLY
Suffix:
Gender:F
Credentials:LMHC, LMSW, IADC
Other - Prefix:
Other - First Name:KIM
Other - Middle Name:
Other - Last Name:KELLY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 658
Mailing Address - Street 2:
Mailing Address - City:OTTUMWA
Mailing Address - State:IA
Mailing Address - Zip Code:52501-0658
Mailing Address - Country:US
Mailing Address - Phone:641-683-6747
Mailing Address - Fax:641-682-1924
Practice Address - Street 1:310 W. MAIN ST
Practice Address - Street 2:
Practice Address - City:OTTUMWA
Practice Address - State:IA
Practice Address - Zip Code:52501
Practice Address - Country:US
Practice Address - Phone:641-683-6747
Practice Address - Fax:641-683-6317
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2017-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA03163104100000X
IA001380101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA228839OtherMIDLANDS CHOICE