Provider Demographics
NPI:1124465554
Name:KELLY, KORRIN TAYLOR
Entity type:Individual
Prefix:
First Name:KORRIN
Middle Name:TAYLOR
Last Name:KELLY
Suffix:
Gender:
Credentials:
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 458
Mailing Address - Street 2:
Mailing Address - City:LOGANDALE
Mailing Address - State:NV
Mailing Address - Zip Code:89021-0458
Mailing Address - Country:US
Mailing Address - Phone:702-624-0499
Mailing Address - Fax:
Practice Address - Street 1:11500 S EASTERN AVE STE 150
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-5576
Practice Address - Country:US
Practice Address - Phone:702-624-0499
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-24
Last Update Date:2025-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician