Provider Demographics
NPI:1821722059
Name:KELLY, WILLIAM (PHD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:
Last Name:KELLY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:LIAM
Other - Middle Name:
Other - Last Name:KELLY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:6617 S HALF MOON DR APT B
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93309-7876
Mailing Address - Country:US
Mailing Address - Phone:412-736-6551
Mailing Address - Fax:
Practice Address - Street 1:2010 W CHESTER PIKE STE 314
Practice Address - Street 2:
Practice Address - City:HAVERTOWN
Practice Address - State:PA
Practice Address - Zip Code:19083-2737
Practice Address - Country:US
Practice Address - Phone:412-736-6551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-13
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC009311101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional