Provider Demographics
NPI:1386108173
Name:KELLEY, KAITLYN ROSE
Entity type:Individual
Prefix:
First Name:KAITLYN
Middle Name:ROSE
Last Name:KELLEY
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 1:2575 TRIAD RD
Mailing Address - Street 2:
Mailing Address - City:SAINT JACOB
Mailing Address - State:IL
Mailing Address - Zip Code:62281-1125
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2575 TRIAD RD
Practice Address - Street 2:
Practice Address - City:SAINT JACOB
Practice Address - State:IL
Practice Address - Zip Code:62281-1125
Practice Address - Country:US
Practice Address - Phone:618-978-5847
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-25
Last Update Date:2019-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool