Healthcare Provider Details

I. General information

NPI: 1598933616
Provider Name (Legal Business Name): GRACE P KELLY MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2008
Last Update Date: 02/17/2025
Certification Date: 02/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5003 POPLAR SPRINGS DR
MERIDIAN MS
39305-1625
US

IV. Provider business mailing address

5000 HIGHWAY 39 N
MERIDIAN MS
39301-1021
US

V. Phone/Fax

Practice location:
  • Phone: 601-453-5393
  • Fax: 888-735-7202
Mailing address:
  • Phone: 601-453-5393
  • Fax: 601-581-9936

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberMS11556
License Number StateMS

VIII. Authorized Official

Name: DR. GRACE PATRICIA KELLY
Title or Position: OWNER
Credential: MD
Phone: 601-453-5393