Provider Demographics
NPI:1225193246
Name:KELLY, ABESIE (PHD)
Entity Type:Individual
Prefix:
First Name:ABESIE
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 W SOUTHERN PINES DR
Mailing Address - Street 2:
Mailing Address - City:PINE BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:71603-6926
Mailing Address - Country:US
Mailing Address - Phone:501-309-8401
Mailing Address - Fax:
Practice Address - Street 1:20 W SOUTHERN PINES DR
Practice Address - Street 2:
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71603-6926
Practice Address - Country:US
Practice Address - Phone:501-309-8401
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301012809103TC0700X
AR97-11P103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical