Healthcare Provider Details

I. General information

NPI: 1821263724
Provider Name (Legal Business Name): CARRIE L KELLY LPC, SACIT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2008
Last Update Date: 04/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

W4051 COUNTY ROAD NN
ELKHORN WI
53121-4338
US

IV. Provider business mailing address

PO BOX 1005
ELKHORN WI
53121-1005
US

V. Phone/Fax

Practice location:
  • Phone: 262-741-3200
  • Fax: 262-741-3217
Mailing address:
  • Phone: 262-741-3200
  • Fax: 262-741-3217

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number4558-125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: