Basic Information
| Provider Information | |||||||||
| NPI: | 1972513299 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLY | ||||||||
| FirstName: | VICTORIA | ||||||||
| MiddleName: | CALVINA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4707 CABRIOLET LN. | ||||||||
| Address2: | |||||||||
| City: | MAUMEE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43537 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5674555432 | ||||||||
| FaxNumber: | 5673166444 | ||||||||
| Practice Location | |||||||||
| Address1: | 3125 TRANSVERSE DR. | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436145811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193835695 | ||||||||
| FaxNumber: | 4193833032 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 35086512 | OH | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 2854915 | 05 | OH | MEDICAID |