Basic Information
| Provider Information | |||||||||
| NPI: | 1396986170 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLY | ||||||||
| FirstName: | H | ||||||||
| MiddleName: | GREGORY | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MS, LPC, LSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3130 N DIXIE HWY | ||||||||
| Address2: | |||||||||
| City: | TROY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453731337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374407626 | ||||||||
| FaxNumber: | 9374407702 | ||||||||
| Practice Location | |||||||||
| Address1: | 3130 N DIXIE HWY | ||||||||
| Address2: | |||||||||
| City: | TROY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453731337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374407626 | ||||||||
| FaxNumber: | 9374407702 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2009 | ||||||||
| LastUpdateDate: | 03/09/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | C0004103-SUPV | OH | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.