Provider Demographics
NPI:1225756547
Name:KELLY, BARRY A
Entity Type:Individual
Prefix:
First Name:BARRY
Middle Name:A
Last Name:KELLY
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 1:1170 BORDER AVE APT A
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92882-6511
Mailing Address - Country:US
Mailing Address - Phone:909-633-2080
Mailing Address - Fax:
Practice Address - Street 1:1170 BORDER AVE APT A
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92882-6511
Practice Address - Country:US
Practice Address - Phone:909-633-2080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-22
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health