Healthcare Provider Details

I. General information

NPI: 1720746308
Provider Name (Legal Business Name): TIMOTHY J KELLY MA, LCPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2021
Last Update Date: 12/01/2021
Certification Date: 11/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9400 LEBANON RD
EAST SAINT LOUIS IL
62203-2214
US

IV. Provider business mailing address

9400 LEBANON RD
EAST SAINT LOUIS IL
62203-2214
US

V. Phone/Fax

Practice location:
  • Phone: 618-397-0968
  • Fax:
Mailing address:
  • Phone: 618-397-0968
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number180013984
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180013984
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: