Healthcare Provider Details

I. General information

NPI: 1477663763
Provider Name (Legal Business Name): THERESA ANN KELLY PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 W MAIN ST
MARION IL
62959-1188
US

IV. Provider business mailing address

100 NORTH 43RD STREET
HERRIN IL
62948
US

V. Phone/Fax

Practice location:
  • Phone: 618-997-5311
  • Fax:
Mailing address:
  • Phone: 618-364-4415
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071-006782
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: