Provider Demographics
NPI:1710702162
Name:KELLY, MADELINE
Entity type:Individual
Prefix:
First Name:MADELINE
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 TWADDELL MILL RD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19807-1223
Mailing Address - Country:US
Mailing Address - Phone:662-736-0266
Mailing Address - Fax:
Practice Address - Street 1:8 POLLY DRUMMOND HILL RD
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19711-5703
Practice Address - Country:US
Practice Address - Phone:302-738-6859
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-20
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN88001791A101YM0800X
DEAC-0010442101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health