Provider Demographics
NPI:1992936280
Name:MILLS, KELLY (LAC)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:
Last Name:MILLS
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:MS
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:CATUGAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAC
Mailing Address - Street 1:3003 N CENTRAL AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2902
Mailing Address - Country:US
Mailing Address - Phone:602-685-6000
Mailing Address - Fax:602-685-6001
Practice Address - Street 1:1415 N 1ST ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85004-1604
Practice Address - Country:US
Practice Address - Phone:602-685-6000
Practice Address - Fax:602-685-6000
Is Sole Proprietor?:No
Enumeration Date:2009-08-04
Last Update Date:2009-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-12221101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health