Healthcare Provider Details

I. General information

NPI: 1780737528
Provider Name (Legal Business Name): CARRIE KELLEY PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/18/2007
Last Update Date: 11/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 E SOUTH TEMPLE SUITE 101
SALT LAKE CITY UT
84111-1247
US

IV. Provider business mailing address

275 E SOUTH TEMPLE SUITE 101
SALT LAKE CITY UT
84111-1247
US

V. Phone/Fax

Practice location:
  • Phone: 801-999-0639
  • Fax: 800-136-4143
Mailing address:
  • Phone: 801-999-0639
  • Fax: 800-136-4143

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number70077562501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: