Provider Demographics
NPI:1245635382
Name:MILLS, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MILLS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:94210 HOLDENBURY DR
Mailing Address - Street 2:UNIT B
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13603-3268
Mailing Address - Country:US
Mailing Address - Phone:580-699-1661
Mailing Address - Fax:
Practice Address - Street 1:94210 HOLDENBURY DR
Practice Address - Street 2:UNIT B
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13603-3268
Practice Address - Country:US
Practice Address - Phone:580-373-2820
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-31
Last Update Date:2025-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4068101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty