Provider Demographics
NPI:1730168543
Name:NEELY, KATHRYN (PSYD)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:NEELY
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 SOUTH GRAHAM AVENUE
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-3001
Mailing Address - Country:US
Mailing Address - Phone:618-457-2700
Mailing Address - Fax:618-457-2700
Practice Address - Street 1:101 SOUTH GRAHAM AVENUE
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-3001
Practice Address - Country:US
Practice Address - Phone:618-457-2700
Practice Address - Fax:618-457-2700
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
7221104OtherAETNA
03932041OtherBCBS
045501OtherHEALTH ALLIANCE
402463OtherHEALTHLINK
402463OtherHEALTHLINK