Provider Demographics
NPI:1154490316
Name:KELLEY, BRAD (LCSW, LCAC)
Entity Type:Individual
Prefix:
First Name:BRAD
Middle Name:
Last Name:KELLEY
Suffix:
Gender:M
Credentials:LCSW, LCAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516 NATIONAL RD W
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:IN
Mailing Address - Zip Code:47374-4018
Mailing Address - Country:US
Mailing Address - Phone:765-914-9116
Mailing Address - Fax:765-488-0930
Practice Address - Street 1:516 NATIONAL RD W
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:IN
Practice Address - Zip Code:47374-4018
Practice Address - Country:US
Practice Address - Phone:765-914-9116
Practice Address - Fax:765-488-0930
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2013-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN87000659A101YA0400X
IN34006759A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)