Provider Demographics
NPI:1699175000
Name:VICKREY, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:VICKREY
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:PO BOX 923
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85244-0923
Mailing Address - Country:US
Mailing Address - Phone:602-370-1742
Mailing Address - Fax:
Practice Address - Street 1:3042 W QUEEN CREEK RD
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85248-2815
Practice Address - Country:US
Practice Address - Phone:520-796-2600
Practice Address - Fax:520-796-2649
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-04
Last Update Date:2024-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC-11614101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)