Provider Demographics
NPI:1346667987
Name:KELLEY, LARRY
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:
Last Name:KELLEY
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 1:6805 NE LOOP 820
Mailing Address - Street 2:SUITE 408
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76180-6687
Mailing Address - Country:US
Mailing Address - Phone:817-581-7246
Mailing Address - Fax:817-581-7248
Practice Address - Street 1:6805 NE LOOP 820
Practice Address - Street 2:SUITE 408
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76180-6687
Practice Address - Country:US
Practice Address - Phone:817-581-7246
Practice Address - Fax:817-581-7248
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-20
Last Update Date:2014-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator