Provider Demographics
NPI:1720024607
Name:HERN, KELLY LOWELL (PHD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:LOWELL
Last Name:HERN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 DEEPSTEP RD NE
Mailing Address - Street 2:
Mailing Address - City:MILLEDGEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31061-9511
Mailing Address - Country:US
Mailing Address - Phone:478-453-1146
Mailing Address - Fax:478-453-1146
Practice Address - Street 1:102 DEEPSTEP RD NE
Practice Address - Street 2:
Practice Address - City:MILLEDGEVILLE
Practice Address - State:GA
Practice Address - Zip Code:31061-9511
Practice Address - Country:US
Practice Address - Phone:478-453-1146
Practice Address - Fax:478-453-1146
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY001660103G00000X, 103TF0200X
KYKY-0862103G00000X, 103T00000X
IN20040782A103G00000X, 103T00000X
GAPSY1660103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA68BBDNGMedicare ID - Type Unspecified
GAR54513Medicare UPIN