MEDICARE: DR. THOMAS E. KELLY PSY.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	3386-125	WI
2	101YP2500X	Professional Counselor	00871	IA
3	101YP2500X	Professional Counselor	00018	MN
4	101YP2500X	Professional Counselor	180-003674	IL
5	103TC0700X	Clinical Psychologist	LP5043	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1972607562
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THOMAS E. KELLY PSY.D.

Provider Business Mailing Address
First Line	:	2399 ARIEL ST N
Second Line	:	SUITE D
City	:	MAPLEWOOD
State	:	MN
Zip	:	55109-2203
Country	:	US
Telephone Number	:	651-770-1311
Fax Number	:	651-770-1879

Provider Business Practice Location Address
First Line	:	108 S MINNESOTA AVE STE 102
Second Line	:
City	:	SAINT PETER
State	:	MN
Zip	:	56082-2557
Country	:	US
Telephone Number	:	507-484-2400
Fax Number	:	507-934-5220

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/12/2006
Last Update Date	:	03/17/2018

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Directions to “ DR. THOMAS E. KELLY PSY.D.” Practice Location

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