Provider Demographics
NPI:1912597170
Name:MCINTYRE, KELLEY RAE
Entity type:Individual
Prefix:MRS
First Name:KELLEY
Middle Name:RAE
Last Name:MCINTYRE
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:KELLEY
Other - Middle Name:RAE
Other - Last Name:MOYER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:304 MARAM WAY
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN
Mailing Address - State:CO
Mailing Address - Zip Code:80817-1511
Mailing Address - Country:US
Mailing Address - Phone:719-209-6787
Mailing Address - Fax:
Practice Address - Street 1:328 SWOPE AVE
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-5837
Practice Address - Country:US
Practice Address - Phone:719-635-1332
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-21
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0110909101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health