Provider Demographics
NPI:1063261147
Name:DUFFIELD, KELLY (EDS, MA, NCSP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:DUFFIELD
Suffix:
Gender:F
Credentials:EDS, MA, NCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 CENTER ST
Mailing Address - Street 2:
Mailing Address - City:CLAY
Mailing Address - State:WV
Mailing Address - Zip Code:25043-7046
Mailing Address - Country:US
Mailing Address - Phone:304-587-2867
Mailing Address - Fax:
Practice Address - Street 1:122 CENTER ST
Practice Address - Street 2:
Practice Address - City:CLAY
Practice Address - State:WV
Practice Address - Zip Code:25043-7046
Practice Address - Country:US
Practice Address - Phone:304-587-2867
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-13
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVL9A131700210103TS0200X
171M00000X
WV103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
No171M00000XOther Service ProvidersCase Manager/Care Coordinator