Healthcare Provider Details

I. General information

NPI: 1710026372
Provider Name (Legal Business Name): KELLEY HAVILL LMFT, LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 07/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3925 HAGAN ST 203
BLOOMINGTON IN
47401
US

IV. Provider business mailing address

3925 HAGAN ST 203
BLOOMINGTON IN
47401-8556
US

V. Phone/Fax

Practice location:
  • Phone: 812-334-0001
  • Fax: 812-334-0001
Mailing address:
  • Phone: 812-333-9895
  • Fax: 812-334-0001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number39001493A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number35001502A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: