Provider Demographics
NPI:1124311907
Name:KELLEY, MARY MARTHA (LPC)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:MARTHA
Last Name:KELLEY
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5546 W TUMBLING F ST
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85713-4453
Mailing Address - Country:US
Mailing Address - Phone:520-975-5305
Mailing Address - Fax:520-838-8698
Practice Address - Street 1:4550 E FIFTH ST
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85711
Practice Address - Country:US
Practice Address - Phone:520-975-5305
Practice Address - Fax:520-838-8698
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-26
Last Update Date:2011-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-11795101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional