Provider Demographics
NPI:1982948725
Name:KELLY, TRACY SUSAN (MA MFT INTERN)
Entity Type:Individual
Prefix:MS
First Name:TRACY
Middle Name:SUSAN
Last Name:KELLY
Suffix:
Gender:F
Credentials:MA MFT INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 50237
Mailing Address - Street 2:
Mailing Address - City:SPARKS
Mailing Address - State:NV
Mailing Address - Zip Code:89435-0237
Mailing Address - Country:US
Mailing Address - Phone:775-742-7764
Mailing Address - Fax:775-622-4509
Practice Address - Street 1:505 S ARLINGTON AVE STE 212-D
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89509-1527
Practice Address - Country:US
Practice Address - Phone:775-742-7764
Practice Address - Fax:775-622-4509
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-17
Last Update Date:2012-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV106H00000X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)