Provider Demographics
NPI:1659868941
Name:KELLEY, PATRICK C (LCDCIII, QMHS)
Entity type:Individual
Prefix:
First Name:PATRICK
Middle Name:C
Last Name:KELLEY
Suffix:
Gender:M
Credentials:LCDCIII, QMHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:OH
Mailing Address - Zip Code:45662-3944
Mailing Address - Country:US
Mailing Address - Phone:740-354-7702
Mailing Address - Fax:740-353-1662
Practice Address - Street 1:225 CARLTON DAVIDSON LN
Practice Address - Street 2:
Practice Address - City:COAL GROVE
Practice Address - State:OH
Practice Address - Zip Code:45638-2924
Practice Address - Country:US
Practice Address - Phone:740-533-0648
Practice Address - Fax:740-353-1662
Is Sole Proprietor?:No
Enumeration Date:2018-04-23
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLCDCIII.162407101YA0400X
OHC.2305166-TRNE101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0361745Medicaid