Provider Demographics
NPI:1245782408
Name:KELLY, JAMES
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:
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 1:170 PEARL ST SE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30316-1247
Mailing Address - Country:US
Mailing Address - Phone:404-588-9065
Mailing Address - Fax:
Practice Address - Street 1:170 PEARL ST SE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30316-1247
Practice Address - Country:US
Practice Address - Phone:404-588-9065
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-03
Last Update Date:2016-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1-05-2292103K00000X
GAPSY002770103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA875847786BMedicaid