Active NPI
Theresa Ann Kelly, PSY.D.
- Clinical Psychologist
- Marion, IL
National Provider Identifier
1477663763
On this page
OIG exclusion record
The HHS Office of Inspector General’s List of Excluded Individuals/Entities (LEIE) contains a record with this NPI:
- Section 1128a(1) exclusion effective Jan 20, 2025.
Key facts
NPPES NPI Registry- Primary specialty
- Clinical Psychologist
- License
- 071-006782
- Practice address
- 2401 W Main St
Marion, IL 62959-1188 - Phone
- (618) 997-5311
- NPI assigned
- Aug 30, 2006
- Last updated
- Jul 8, 2007
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Clinical Psychologist | 103TC0700X | 071-006782 | IL | Primary |
Addresses
Primary practice location
2401 W Main St
Marion, IL 62959-1188
Mailing address
100 North 43Rd Street
Herrin, IL 62948
Phone (618) 364-4415
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
- HHS exclusion list flag
- Flagged The directory lists this NPI on an HHS exclusion list.
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 071-006782 | IL | MD | Clinical Psychologist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Southern Il Regional Social Services | Past | Accepting new patients |
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.
-
- Community/Behavioral Health Agency
- Carbondale, IL
- NPI 1083851182
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1156896000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183852800000",
"number": "1477663763",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "100 NORTH 43RD STREET",
"city": "HERRIN",
"state": "IL",
"postal_code": "62948",
"telephone_number": "618-364-4415"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "2401 W MAIN ST",
"city": "MARION",
"state": "IL",
"postal_code": "629591188",
"telephone_number": "618-997-5311"
}
],
"practiceLocations": [],
"basic": {
"last_name": "KELLY",
"first_name": "THERESA",
"middle_name": "ANN",
"name_prefix": "Dr.",
"credential": "PSY.D.",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2006-08-30",
"last_updated": "2007-07-08",
"status": "A"
},
"taxonomies": [
{
"code": "103TC0700X",
"taxonomy_group": "",
"desc": "Psychologist, Clinical",
"state": "IL",
"license": "071-006782",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Marion, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; OIG LEIE.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.