Provider Demographics
NPI:1952453821
Name:KELLY, MARY S (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:S
Last Name:KELLY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1165 MORRIS PARK AVE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10461-1915
Mailing Address - Country:US
Mailing Address - Phone:718-430-3908
Mailing Address - Fax:718-430-3989
Practice Address - Street 1:1165 MORRIS PARK AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-1915
Practice Address - Country:US
Practice Address - Phone:718-430-3908
Practice Address - Fax:718-430-3989
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011605103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYV91531Medicare ID - Type Unspecified