Provider Demographics
NPI:1902967227
Name:KELLY, MIKE B (MA, LIMHP, PLADC,)
Entity Type:Individual
Prefix:
First Name:MIKE
Middle Name:B
Last Name:KELLY
Suffix:
Gender:M
Credentials:MA, LIMHP, PLADC,
Other - Prefix:
Other - First Name:MICHAEL
Other - Middle Name:B
Other - Last Name:KELLY-DEFREECE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3810 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:KEARNEY
Mailing Address - State:NE
Mailing Address - Zip Code:68847-8134
Mailing Address - Country:US
Mailing Address - Phone:083-237-5951
Mailing Address - Fax:308-234-4018
Practice Address - Street 1:3810 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:KEARNEY
Practice Address - State:NE
Practice Address - Zip Code:68847-8134
Practice Address - Country:US
Practice Address - Phone:308-237-5951
Practice Address - Fax:308-234-4018
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2019-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NEP-939101YA0400X
NE2718101YM0800X
NE1446101YP2500X
NE928101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025451701Medicaid