Provider Demographics
NPI:1184720088
Name:KELLEY, DAVID J (PHD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:J
Last Name:KELLEY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:756 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12208-3823
Mailing Address - Country:US
Mailing Address - Phone:518-689-1399
Mailing Address - Fax:
Practice Address - Street 1:632 PLANK RD
Practice Address - Street 2:SUITE 209
Practice Address - City:CLIFTON PARK
Practice Address - State:NY
Practice Address - Zip Code:12065
Practice Address - Country:US
Practice Address - Phone:518-689-1399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2012-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014048-1103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist