Provider Demographics
NPI:1356639603
Name:NABAL, KELLY ANN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:ANN
Last Name:NABAL
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 SOUTH BROAD STREET
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19110
Mailing Address - Country:US
Mailing Address - Phone:215-701-1560
Mailing Address - Fax:215-701-1575
Practice Address - Street 1:100 S BROAD ST
Practice Address - Street 2:17TH FLOOR
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19110-1023
Practice Address - Country:US
Practice Address - Phone:215-701-1560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-20
Last Update Date:2011-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS017024103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical