Provider Demographics
NPI:1346815230
Name:KELLY, TYDARIAN ROSHAWN
Entity Type:Individual
Prefix:
First Name:TYDARIAN
Middle Name:ROSHAWN
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 1:2675 COURT DR
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-1478
Mailing Address - Country:US
Mailing Address - Phone:704-824-4999
Mailing Address - Fax:
Practice Address - Street 1:852 PERRY RD
Practice Address - Street 2:
Practice Address - City:APEX
Practice Address - State:NC
Practice Address - Zip Code:27502-7701
Practice Address - Country:US
Practice Address - Phone:919-446-5670
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-24
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician