Provider Demographics
NPI:1104708437
Name:KELLY, MARK ALLEN (P-LPC)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:ALLEN
Last Name:KELLY
Suffix:
Gender:M
Credentials:P-LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2094 OLD TAYLOR RD STE 157
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-5019
Mailing Address - Country:US
Mailing Address - Phone:601-790-0583
Mailing Address - Fax:
Practice Address - Street 1:2094 OLD TAYLOR RD STE 157
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-5019
Practice Address - Country:US
Practice Address - Phone:601-790-0583
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-25
Last Update Date:2025-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor