Provider Demographics
NPI:1144286758
Name:KELLEY, MARIANNE P (PSYD LP)
Entity type:Individual
Prefix:MS
First Name:MARIANNE
Middle Name:P
Last Name:KELLEY
Suffix:
Gender:F
Credentials:PSYD LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:821 RAYMOND AVE
Mailing Address - Street 2:#200
Mailing Address - City:ST PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55114-1509
Mailing Address - Country:US
Mailing Address - Phone:651-645-8300
Mailing Address - Fax:651-645-4603
Practice Address - Street 1:821 RAYMOND AVE
Practice Address - Street 2:#200
Practice Address - City:ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55114-1509
Practice Address - Country:US
Practice Address - Phone:651-645-8300
Practice Address - Fax:651-645-4603
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3511103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN01014479OtherPREFERRED ONE
MN06Q72KEOtherBLUE CROSS
MNHP18714OtherHEALTH PARTNERS