Provider Demographics
NPI:1093847584
Name:KELLEY, KEVIN J (PHD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:J
Last Name:KELLEY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 UNION BLVD
Mailing Address - Street 2:
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18109-3230
Mailing Address - Country:US
Mailing Address - Phone:610-435-1541
Mailing Address - Fax:610-435-4367
Practice Address - Street 1:530 UNION BLVD
Practice Address - Street 2:
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18109-3230
Practice Address - Country:US
Practice Address - Phone:610-435-1541
Practice Address - Fax:610-435-4367
Is Sole Proprietor?:No
Enumeration Date:2007-03-10
Last Update Date:2014-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS005818L103TA0700X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA763740OtherBLUE SHIELD