1144286758 NPI number — MS. MARIANNE P KELLEY PSYD LP

Table of content: MS. MARIANNE P KELLEY PSYD LP (NPI 1144286758)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144286758 NPI number — MS. MARIANNE P KELLEY PSYD LP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KELLEY
Provider First Name:
MARIANNE
Provider Middle Name:
P
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
PSYD LP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1144286758
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
821 RAYMOND AVE
Provider Second Line Business Mailing Address:
#200
Provider Business Mailing Address City Name:
ST PAUL
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55114-1509
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-645-8300
Provider Business Mailing Address Fax Number:
651-645-4603

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
821 RAYMOND AVE
Provider Second Line Business Practice Location Address:
#200
Provider Business Practice Location Address City Name:
ST PAUL
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55114-1509
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-645-8300
Provider Business Practice Location Address Fax Number:
651-645-4603
Provider Enumeration Date:
04/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  LP3511 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 01014479 . This is a "PREFERRED ONE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 06Q72KE . This is a "BLUE CROSS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: HP18714 . This is a "HEALTH PARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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