Provider Demographics
NPI:1285479089
Name:KELLY, MEGHAN (BS CRIMINOLOGY)
Entity type:Individual
Prefix:
First Name:MEGHAN
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:BS CRIMINOLOGY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5384 E WOODLAND DR
Mailing Address - Street 2:
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854-4505
Mailing Address - Country:US
Mailing Address - Phone:209-662-0871
Mailing Address - Fax:
Practice Address - Street 1:827 W PRAIRIE AVE
Practice Address - Street 2:
Practice Address - City:HAYDEN
Practice Address - State:ID
Practice Address - Zip Code:83835-8459
Practice Address - Country:US
Practice Address - Phone:208-719-7158
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-25
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician