MEDICARE: KELLY DALLAIRE LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	7682-125	WI

General Provider Information

NPI Number	:	1316338866
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY DALLAIRE LPC

Provider Business Mailing Address
First Line	:	615 REID ST
Second Line	:
City	:	DE PERE
State	:	WI
Zip	:	54115-1346
Country	:	US
Telephone Number	:	920-737-7695
Fax Number	:

Provider Business Practice Location Address
First Line	:	425 S ADAMS ST STE 205
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54301-4117
Country	:	US
Telephone Number	:	920-737-7695
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/05/2015
Last Update Date	:	06/02/2026

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