Provider Demographics
NPI:1447902473
Name:DONISTHORPE, KELLEY M (PHD, LCPC)
Entity type:Individual
Prefix:
First Name:KELLEY
Middle Name:M
Last Name:DONISTHORPE
Suffix:
Gender:F
Credentials:PHD, LCPC
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 3043
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59806-3043
Mailing Address - Country:US
Mailing Address - Phone:406-531-2421
Mailing Address - Fax:
Practice Address - Street 1:103 BEN HOGAN DR
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59803-2422
Practice Address - Country:US
Practice Address - Phone:406-531-2421
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-20
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-LCPC-LIC-54991101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional