Provider Demographics
NPI:1801977863
Name:KELLY, SUZANNE MAXINE (LMFT)
Entity type:Individual
Prefix:MRS
First Name:SUZANNE
Middle Name:MAXINE
Last Name:KELLY
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2520 COON RAPIDS BLVD NW
Mailing Address - Street 2:STE 260
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-3908
Mailing Address - Country:US
Mailing Address - Phone:763-576-0728
Mailing Address - Fax:763-560-7453
Practice Address - Street 1:2520 COON RAPIDS BLVD NW STE 260
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-3908
Practice Address - Country:US
Practice Address - Phone:763-576-0728
Practice Address - Fax:763-560-7453
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1121106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist