Provider Demographics
NPI:1699288498
Name:KELLY, VINCENT (MS, CRC, TLMHC)
Entity type:Individual
Prefix:
First Name:VINCENT
Middle Name:
Last Name:KELLY
Suffix:
Gender:
Credentials:MS, CRC, TLMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3839 MERLE HAY RD STE 227
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50310-1312
Mailing Address - Country:US
Mailing Address - Phone:515-669-8111
Mailing Address - Fax:
Practice Address - Street 1:3839 MERLE HAY RD STE 227
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50310-1312
Practice Address - Country:US
Practice Address - Phone:515-669-8111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-15
Last Update Date:2025-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA083011101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN$$$$$$$$$OtherSOCIAL SECURITIY NUMBER