Provider Demographics
NPI:1487342648
Name:KELLY, SEAN E
Entity type:Individual
Prefix:
First Name:SEAN
Middle Name:E
Last Name:KELLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 W MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:BARTLEY
Mailing Address - State:NE
Mailing Address - Zip Code:69020-2200
Mailing Address - Country:US
Mailing Address - Phone:308-737-1445
Mailing Address - Fax:
Practice Address - Street 1:301 NELSON ST
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:NE
Practice Address - Zip Code:69022
Practice Address - Country:US
Practice Address - Phone:308-737-1445
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-26
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1167101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)