Healthcare Provider Details

I. General information

NPI: 1154452969
Provider Name (Legal Business Name): KELLY E BAIN-CONKIN MS, LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 01/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 N MICHIGAN ST SUITE 208
PLYMOUTH IN
46563-1770
US

IV. Provider business mailing address

310 N MICHIGAN ST SUITE 208
PLYMOUTH IN
46563-1770
US

V. Phone/Fax

Practice location:
  • Phone: 574-935-9449
  • Fax: 574-935-3956
Mailing address:
  • Phone: 574-935-9449
  • Fax: 574-935-3956

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number39002134A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: