Provider Demographics
NPI:1205052487
Name:KELLY, KENNETH GREGORY (PSYCHOLOGIST-MA)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:GREGORY
Last Name:KELLY
Suffix:
Gender:M
Credentials:PSYCHOLOGIST-MA
Other - Prefix:PROF
Other - First Name:K
Other - Middle Name:G
Other - Last Name:KELLY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1401
Mailing Address - Street 2:
Mailing Address - City:MORRISVILLE
Mailing Address - State:VT
Mailing Address - Zip Code:05661-1401
Mailing Address - Country:US
Mailing Address - Phone:802-635-9595
Mailing Address - Fax:802-635-7755
Practice Address - Street 1:2297 KNOWLES FLAT RD
Practice Address - Street 2:
Practice Address - City:EDEN
Practice Address - State:VT
Practice Address - Zip Code:05652
Practice Address - Country:US
Practice Address - Phone:802-635-9595
Practice Address - Fax:802-635-7755
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical