Provider Demographics
NPI:1942901293
Name:KELLY, LAWRENCE EVERRETT
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:EVERRETT
Last Name:KELLY
Suffix:
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 1:15018 CARLSBAD RD
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22193-1606
Mailing Address - Country:US
Mailing Address - Phone:703-270-8403
Mailing Address - Fax:
Practice Address - Street 1:15018 CARLSBAD RD
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22193-1606
Practice Address - Country:US
Practice Address - Phone:703-270-8403
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-14
Last Update Date:2023-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician