Basic Information
| Provider Information | |||||||||
| NPI: | 1306041595 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLY | ||||||||
| FirstName: | KATINA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PSYD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1010 CEDAR HILL CHURCH RD | ||||||||
| Address2: | |||||||||
| City: | JONESVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 242637219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5072265759 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1010 CEDAR HILL CHURCH RD | ||||||||
| Address2: | |||||||||
| City: | JONESVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 242637219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5072265759 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2007 | ||||||||
| LastUpdateDate: | 04/20/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 103T00000X | 0810007806 | VA | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.