Provider Demographics
NPI:1942098652
Name:KELLEY, DESERIE BONNIE
Entity type:Individual
Prefix:
First Name:DESERIE
Middle Name:BONNIE
Last Name:KELLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BONNIE
Other - Middle Name:
Other - Last Name:KELLEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:401 RAILROAD ST W
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59802-4178
Mailing Address - Country:US
Mailing Address - Phone:406-258-4789
Mailing Address - Fax:406-258-4732
Practice Address - Street 1:2210 MULLAN RD
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59808-2059
Practice Address - Country:US
Practice Address - Phone:406-493-7041
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-30
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-BHPS-CRT-78905175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist