Provider Demographics
NPI:1215158746
Name:BEACH, KELLY MAE (MA)
Entity type:Individual
Prefix:MS
First Name:KELLY
Middle Name:MAE
Last Name:BEACH
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3652 N. RANCHO DR.
Mailing Address - Street 2:STE. 102
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89130
Mailing Address - Country:US
Mailing Address - Phone:702-334-6162
Mailing Address - Fax:702-515-0660
Practice Address - Street 1:3652 N RANCHO DR
Practice Address - Street 2:STE. 102
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89130-3178
Practice Address - Country:US
Practice Address - Phone:702-334-6162
Practice Address - Fax:702-515-0660
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2012-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV01076106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100512262Medicaid