Provider Demographics
NPI:1255829230
Name:KELLY, ANTHONY RINGO JR
Entity Type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:RINGO
Last Name:KELLY
Suffix:JR
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 1:3377 WALLACE ST
Mailing Address - Street 2:
Mailing Address - City:JURUPA VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92509-4660
Mailing Address - Country:US
Mailing Address - Phone:951-236-7721
Mailing Address - Fax:
Practice Address - Street 1:4164 BROCKTON AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501-3400
Practice Address - Country:US
Practice Address - Phone:951-683-5193
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-25
Last Update Date:2018-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst