Provider Demographics
NPI:1801361100
Name:KELLEY, IRVING JR
Entity Type:Individual
Prefix:
First Name:IRVING
Middle Name:
Last Name:KELLEY
Suffix:JR
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 1:3500 POPE ST SE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20020-2356
Mailing Address - Country:US
Mailing Address - Phone:202-439-9123
Mailing Address - Fax:
Practice Address - Street 1:3500 POPE ST SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20020-2356
Practice Address - Country:US
Practice Address - Phone:202-439-9123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-12
Last Update Date:2018-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLGPC00181101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
1903OtherBUSINESS
1973OtherBUSINESS