Basic Information
| Provider Information | |||||||||
| NPI: | 1003877895 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLY | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | PHD, LMHC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1824 | ||||||||
| Address2: | |||||||||
| City: | CEDAR RAPIDS | ||||||||
| State: | IA | ||||||||
| PostalCode: | 524061824 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3193694505 | ||||||||
| FaxNumber: | 3193694677 | ||||||||
| Practice Location | |||||||||
| Address1: | 5264 COUNCIL ST NE | ||||||||
| Address2: | STE 400 | ||||||||
| City: | CEDAR RAPIDS | ||||||||
| State: | IA | ||||||||
| PostalCode: | 524022471 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3193986694 | ||||||||
| FaxNumber: | 3193694673 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 00408 | IA | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.