Provider Demographics
NPI:1831274562
Name:KELLY, MICHELE (PSYD)
Entity type:Individual
Prefix:
First Name:MICHELE
Middle Name:
Last Name:KELLY
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 1:1825 MARION ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80218-1122
Mailing Address - Country:US
Mailing Address - Phone:303-861-9792
Mailing Address - Fax:
Practice Address - Street 1:1205 ONEIDA ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80220-2944
Practice Address - Country:US
Practice Address - Phone:303-861-6792
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2008-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1713103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO07025125Medicaid
CO07025125Medicaid
U1186Medicare ID - Type Unspecified