Provider Demographics
NPI:1164916789
Name:KELLY, CAROLINE (LPCC)
Entity type:Individual
Prefix:
First Name:CAROLINE
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4969 OLSON MEMORIAL HWY
Mailing Address - Street 2:
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55422-5138
Mailing Address - Country:US
Mailing Address - Phone:763-575-8086
Mailing Address - Fax:
Practice Address - Street 1:4969 OLSON MEMORIAL HWY
Practice Address - Street 2:
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55422-5138
Practice Address - Country:US
Practice Address - Phone:763-575-8086
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-18
Last Update Date:2025-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4175101YP2500X, 101YP2500X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician