Provider Demographics
NPI:1508135252
Name:KELLY, JOHN
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:
Last Name:KELLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JACK
Other - Middle Name:
Other - Last Name:KELLY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CAP,NLP,LHP
Mailing Address - Street 1:9170 SW 14TH ST APT 4107
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33428-6829
Mailing Address - Country:US
Mailing Address - Phone:561-603-1807
Mailing Address - Fax:
Practice Address - Street 1:4550 LANTANA ROAD
Practice Address - Street 2:SUITE A4
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33463
Practice Address - Country:US
Practice Address - Phone:561-340-7259
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-27
Last Update Date:2011-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3217101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)