Healthcare Provider Details

I. General information

NPI: 1134995582
Provider Name (Legal Business Name): KELLEY MICHELE STANLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2023
Last Update Date: 04/11/2024
Certification Date: 04/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

49 OLIVE ST
GALLIPOLIS OH
45631-1632
US

IV. Provider business mailing address

PO BOX 272
GALLIPOLIS OH
45631-0272
US

V. Phone/Fax

Practice location:
  • Phone: 740-441-5809
  • Fax: 740-578-9242
Mailing address:
  • Phone: 740-441-5809
  • Fax: 740-578-9242

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.187974
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: