Provider Demographics
NPI:1720187321
Name:KELLY, ROGER BRUCE (MA)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:BRUCE
Last Name:KELLY
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 N 12TH ST STE 100
Mailing Address - Street 2:
Mailing Address - City:LEMOYNE
Mailing Address - State:PA
Mailing Address - Zip Code:17043-1244
Mailing Address - Country:US
Mailing Address - Phone:717-730-0733
Mailing Address - Fax:717-730-0696
Practice Address - Street 1:525 N 12TH ST STE 100
Practice Address - Street 2:
Practice Address - City:LEMOYNE
Practice Address - State:PA
Practice Address - Zip Code:17043-1244
Practice Address - Country:US
Practice Address - Phone:717-730-0733
Practice Address - Fax:717-730-0696
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS005648L103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA01101101OtherBLUE CROSS
PA678552OtherBLUE SHIELD
PA0015265280003Medicaid