Provider Demographics
NPI:1619984309
Name:KELLY, KEVIN WILLIAM (PSYD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:WILLIAM
Last Name:KELLY
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2013 STATE STREET
Mailing Address - Street 2:
Mailing Address - City:EAST PETERSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17520-1216
Mailing Address - Country:US
Mailing Address - Phone:717-291-8283
Mailing Address - Fax:717-581-6528
Practice Address - Street 1:2013 STATE STREET
Practice Address - Street 2:
Practice Address - City:EAST PETERSBURG
Practice Address - State:PA
Practice Address - Zip Code:17520-1216
Practice Address - Country:US
Practice Address - Phone:717-291-8283
Practice Address - Fax:717-581-6528
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2010-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS-008835-L103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000411068OtherHIGHMARK BLUE SHIELD #
PA01786901OtherCAPITAL BLUE CROSS PROV#
PA458436OtherVALUE OPTIONS PROV #
PAP00180931OtherRAILROAD MEDICARE PROV #
PA02695800OtherCAPITAL BLUE CROSS PRACT#
PA000411068OtherHIGHMARK BLUE SHIELD #