Basic Information
| Provider Information | |||||||||
| NPI: | 1083886642 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FINN | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MSW, LISAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5022 N 54TH AVE STE 4 | ||||||||
| Address2: | |||||||||
| City: | GLENDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853017531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6239314343 | ||||||||
| FaxNumber: | 6239393476 | ||||||||
| Practice Location | |||||||||
| Address1: | 5022 N 54TH AVE STE 4 | ||||||||
| Address2: | |||||||||
| City: | GLENDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853017531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6239314343 | ||||||||
| FaxNumber: | 6239393476 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2008 | ||||||||
| LastUpdateDate: | 03/24/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | LISAC-10886 | AZ | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 600248032 | 01 | AZ | MAGELLAN PROVIDER ID NUMB | OTHER |