Provider Demographics
NPI:1972309086
Name:KELLY, TASHA JEANMARIE (LAC)
Entity type:Individual
Prefix:
First Name:TASHA
Middle Name:JEANMARIE
Last Name:KELLY
Suffix:
Gender:
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4801 11TH AVE W APT 410
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:ND
Mailing Address - Zip Code:58801-5392
Mailing Address - Country:US
Mailing Address - Phone:406-491-3610
Mailing Address - Fax:
Practice Address - Street 1:2126 VISTA AVE
Practice Address - Street 2:
Practice Address - City:ARNEGARD
Practice Address - State:ND
Practice Address - Zip Code:58835
Practice Address - Country:US
Practice Address - Phone:701-586-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-20
Last Update Date:2025-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)