Provider Demographics
NPI:1164178380
Name:KELLEY, NATHAN SCOTT
Entity Type:Individual
Prefix:MR
First Name:NATHAN
Middle Name:SCOTT
Last Name:KELLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:604 STATE ROUTE 208
Mailing Address - Street 2:
Mailing Address - City:PULASKI
Mailing Address - State:PA
Mailing Address - Zip Code:16143-4104
Mailing Address - Country:US
Mailing Address - Phone:330-519-1594
Mailing Address - Fax:
Practice Address - Street 1:150 PLEASANT DR STE 201
Practice Address - Street 2:
Practice Address - City:ALIQUIPPA
Practice Address - State:PA
Practice Address - Zip Code:15001-1360
Practice Address - Country:US
Practice Address - Phone:724-888-2097
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-25
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PABH005348106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician