Provider Demographics
NPI:1508391665
Name:KELLY, PATRICK JOEL
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:JOEL
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 1:814 D ST APT 3
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95814-0722
Mailing Address - Country:US
Mailing Address - Phone:916-764-7959
Mailing Address - Fax:
Practice Address - Street 1:814 D ST APT 3
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95814-0722
Practice Address - Country:US
Practice Address - Phone:916-764-7959
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-26
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAF1841963106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician