Provider Demographics
NPI:1720013972
Name:KELLEY, PETER (PSYD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:KELLEY
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 1:1 MAIN ST
Mailing Address - Street 2:SUITE 206
Mailing Address - City:NASHUA
Mailing Address - State:NH
Mailing Address - Zip Code:03064-2716
Mailing Address - Country:US
Mailing Address - Phone:603-883-0005
Mailing Address - Fax:603-883-0007
Practice Address - Street 1:1 MAIN ST
Practice Address - Street 2:SUITE 206
Practice Address - City:NASHUA
Practice Address - State:NH
Practice Address - Zip Code:03064-2716
Practice Address - Country:US
Practice Address - Phone:603-883-0005
Practice Address - Fax:603-883-0007
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH846103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RE4790Medicare ID - Type Unspecified