Provider Demographics
NPI:1699041020
Name:KELLY, MICHELLE A (LCMHC)
Entity type:Individual
Prefix:MISS
First Name:MICHELLE
Middle Name:A
Last Name:KELLY
Suffix:
Gender:F
Credentials:LCMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 ASPEN DR
Mailing Address - Street 2:
Mailing Address - City:WANSHIP
Mailing Address - State:UT
Mailing Address - Zip Code:84017-9544
Mailing Address - Country:US
Mailing Address - Phone:801-231-1873
Mailing Address - Fax:
Practice Address - Street 1:4101 N THANKSGIVING WAY
Practice Address - Street 2:
Practice Address - City:LEHI
Practice Address - State:UT
Practice Address - Zip Code:84043-4367
Practice Address - Country:US
Practice Address - Phone:801-341-2308
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-29
Last Update Date:2020-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8669573-6004101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health