Provider Demographics
NPI:1336312974
Name:KELLY, THOMAS MARK
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:MARK
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 1:400 HOLLAND AVE
Mailing Address - Street 2:
Mailing Address - City:BRADDOCK
Mailing Address - State:PA
Mailing Address - Zip Code:15104-1599
Mailing Address - Country:US
Mailing Address - Phone:412-636-5151
Mailing Address - Fax:412-636-5705
Practice Address - Street 1:400 HOLLAND AVE
Practice Address - Street 2:
Practice Address - City:BRADDOCK
Practice Address - State:PA
Practice Address - Zip Code:15104-1599
Practice Address - Country:US
Practice Address - Phone:412-636-5151
Practice Address - Fax:412-636-5705
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-03
Last Update Date:2008-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)