Provider Demographics
NPI:1447479290
Name:KELLY, KIMBERLY (PSYD)
Entity type:Individual
Prefix:
First Name:KIMBERLY
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:PO BOX 2257
Mailing Address - Street 2:
Mailing Address - City:CHESTERTON
Mailing Address - State:IN
Mailing Address - Zip Code:46304-0357
Mailing Address - Country:US
Mailing Address - Phone:219-926-8320
Mailing Address - Fax:219-926-3524
Practice Address - Street 1:3180 RACQUET CLUB DR STE G
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-4797
Practice Address - Country:US
Practice Address - Phone:231-933-4009
Practice Address - Fax:231-933-4032
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist