Provider Demographics
NPI:1548884703
Name:KELLEY, MICHELLE RENEE (LPC)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:RENEE
Last Name:KELLEY
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35139 312TH RD
Mailing Address - Street 2:
Mailing Address - City:CEDAR VALE
Mailing Address - State:KS
Mailing Address - Zip Code:67024-9305
Mailing Address - Country:US
Mailing Address - Phone:620-441-8856
Mailing Address - Fax:
Practice Address - Street 1:35139 312TH RD
Practice Address - Street 2:
Practice Address - City:CEDAR VALE
Practice Address - State:KS
Practice Address - Zip Code:67024-9305
Practice Address - Country:US
Practice Address - Phone:620-441-8856
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-03
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KST-LC101YM0800X
171M00000X
KS3616101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS3616Medicaid