Provider Demographics
NPI:1992434062
Name:KELLY, ALEXANDRA RENEE
Entity type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:RENEE
Last Name:KELLY
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 1:103 CHELAN DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-1334
Mailing Address - Country:US
Mailing Address - Phone:630-808-5297
Mailing Address - Fax:
Practice Address - Street 1:230 N LIMESTONE STE 100
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40507-1027
Practice Address - Country:US
Practice Address - Phone:630-808-5297
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-06
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY276924103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical