Provider Demographics
NPI:1104457530
Name:KELLY, MEGAN L (LAMFT)
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:L
Last Name:KELLY
Suffix:
Gender:F
Credentials:LAMFT
Other - Prefix:
Other - First Name:MEGAN
Other - Middle Name:L
Other - Last Name:WEGNER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:W175N11120 STONEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53022-4799
Mailing Address - Country:US
Mailing Address - Phone:262-345-5533
Mailing Address - Fax:262-293-9737
Practice Address - Street 1:8670 210TH ST W
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55044-7000
Practice Address - Country:US
Practice Address - Phone:800-438-1772
Practice Address - Fax:262-345-5562
Is Sole Proprietor?:No
Enumeration Date:2020-02-04
Last Update Date:2020-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3960106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist