MEDICARE: TIMOTHY J KELLY MA, LCPC

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	101YP2500X	Professional Counselor	180013984	IL
2	101Y00000X	Counselor	180013984	IL

General Provider Information

NPI Number	:	1720746308
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIMOTHY J KELLY MA, LCPC

Provider Business Mailing Address
First Line	:	9400 LEBANON RD
Second Line	:
City	:	EAST SAINT LOUIS
State	:	IL
Zip	:	62203-2214
Country	:	US
Telephone Number	:	618-397-0968
Fax Number	:

Provider Business Practice Location Address
First Line	:	9400 LEBANON RD
Second Line	:
City	:	EAST SAINT LOUIS
State	:	IL
Zip	:	62203-2214
Country	:	US
Telephone Number	:	618-397-0968
Fax Number	:

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

Provider Enumeration Date	:	12/01/2021
Last Update Date	:	12/01/2021

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