Provider Demographics
NPI:1003895251
Name:KELLEY, BRENDA (PTA1770)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:KELLEY
Suffix:
Gender:F
Credentials:PTA1770
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1003 EVERGREEN DR
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-9783
Mailing Address - Country:US
Mailing Address - Phone:870-886-8715
Mailing Address - Fax:870-886-2653
Practice Address - Street 1:1003 EVERGREEN DR
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-9783
Practice Address - Country:US
Practice Address - Phone:870-886-8715
Practice Address - Fax:870-886-2653
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPTA1770174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist