Provider Demographics
NPI:1679288120
Name:KELLY, BRIAN E
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:E
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 1:173 SCOTT LN
Mailing Address - Street 2:
Mailing Address - City:VENETIA
Mailing Address - State:PA
Mailing Address - Zip Code:15367-1115
Mailing Address - Country:US
Mailing Address - Phone:412-737-0305
Mailing Address - Fax:
Practice Address - Street 1:1040 E WINDHAVEN RD
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15205-8700
Practice Address - Country:US
Practice Address - Phone:724-396-1510
Practice Address - Fax:724-972-4627
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-19
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC015266101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional