Provider Demographics
NPI:1780737528
Name:KELLEY, CARRIE (PSYD)
Entity type:Individual
Prefix:DR
First Name:CARRIE
Middle Name:
Last Name:KELLEY
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:275 E SOUTH TEMPLE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84111-1247
Mailing Address - Country:US
Mailing Address - Phone:801-999-0639
Mailing Address - Fax:800-136-4143
Practice Address - Street 1:275 E SOUTH TEMPLE
Practice Address - Street 2:SUITE 101
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111-1247
Practice Address - Country:US
Practice Address - Phone:801-999-0639
Practice Address - Fax:800-136-4143
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2009-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT70077562501103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical