Provider Demographics
NPI:1508029265
Name:KELLY, HENRY ALBERT JR (PHD)
Entity Type:Individual
Prefix:DR
First Name:HENRY
Middle Name:ALBERT
Last Name:KELLY
Suffix:JR
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 1:60 LOCHERN RD
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28358-8664
Mailing Address - Country:US
Mailing Address - Phone:910-739-4130
Mailing Address - Fax:910-739-4130
Practice Address - Street 1:60 LOCHERN RD
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28358-8664
Practice Address - Country:US
Practice Address - Phone:910-739-4130
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-02
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNH620088111101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health