Basic Information
| Provider Information | |||||||||
| NPI: | 1629497094 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KELLY ANGLIN LLC | ||||||||
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| OtherOrganizationName: | ANGLIN FAMILY THERAPY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8205 SPAIN RD NE | ||||||||
| Address2: | SUITE 106 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871093179 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5053847352 | ||||||||
| FaxNumber: | 5052747338 | ||||||||
| Practice Location | |||||||||
| Address1: | 3300 N BUTLER AVE | ||||||||
| Address2: | SUITE 217 | ||||||||
| City: | FARMINGTON | ||||||||
| State: | NM | ||||||||
| PostalCode: | 874015621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5056087398 | ||||||||
| FaxNumber: | 5056347044 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2014 | ||||||||
| LastUpdateDate: | 04/14/2014 | ||||||||
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| AuthorizedOfficialLastName: | ANGLIN | ||||||||
| AuthorizedOfficialFirstName: | KELLY | ||||||||
| AuthorizedOfficialMiddleName: | DARLENE | ||||||||
| AuthorizedOfficialTitleorPosition: | LMFT/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5056087398 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 0162711 | NM | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.