Provider Demographics
NPI:1366443095
Name:KELLEY, NORMAN L (PHD)
Entity Type:Individual
Prefix:
First Name:NORMAN
Middle Name:L
Last Name:KELLEY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 GILBERT RD
Mailing Address - Street 2:
Mailing Address - City:NEW HARTFORD
Mailing Address - State:NY
Mailing Address - Zip Code:13413-2414
Mailing Address - Country:US
Mailing Address - Phone:315-735-6036
Mailing Address - Fax:
Practice Address - Street 1:1 OXFORD XING
Practice Address - Street 2:STE 6
Practice Address - City:NEW HARTFORD
Practice Address - State:NY
Practice Address - Zip Code:13413-3200
Practice Address - Country:US
Practice Address - Phone:315-732-8880
Practice Address - Fax:315-732-2705
Is Sole Proprietor?:No
Enumeration Date:2005-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009959103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY391513OtherMVP
NY02261512Medicaid
NY02261512Medicaid