Provider Demographics
NPI:1104944404
Name:HAGAN, KELLY LYNN (MA)
Entity type:Individual
Prefix:MS
First Name:KELLY
Middle Name:LYNN
Last Name:HAGAN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:MS
Other - First Name:KELLY
Other - Middle Name:LYNN
Other - Last Name:HAGAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LICENSED PSYCH ASSO
Mailing Address - Street 1:1712 BROOK PARK DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40515-1307
Mailing Address - Country:US
Mailing Address - Phone:859-271-9253
Mailing Address - Fax:
Practice Address - Street 1:520 E MAXWELL ST
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40502-6432
Practice Address - Country:US
Practice Address - Phone:859-233-3390
Practice Address - Fax:859-243-9906
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY 0280101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health