Provider Demographics
NPI:1306472659
Name:FRANKLIN, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:FRANKLIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2113 WABASH ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46613-1138
Mailing Address - Country:US
Mailing Address - Phone:574-286-8078
Mailing Address - Fax:
Practice Address - Street 1:4218 W WESTERN AVE
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46619-2622
Practice Address - Country:US
Practice Address - Phone:574-233-1524
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-19
Last Update Date:2020-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN88000846A101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor