Provider Demographics
NPI:1235494774
Name:KELLY, BRIAN J (PHD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:J
Last Name:KELLY
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 1:180 NORTH STREET
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:NY
Mailing Address - Zip Code:13021-1811
Mailing Address - Country:US
Mailing Address - Phone:315-255-2285
Mailing Address - Fax:
Practice Address - Street 1:180 NORTH STREET
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:NY
Practice Address - Zip Code:13021-1811
Practice Address - Country:US
Practice Address - Phone:315-255-2285
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-11
Last Update Date:2013-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020001103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling