Provider Demographics
NPI:1255615217
Name:KELLY, THOMPSON JAMES JR (PHD)
Entity type:Individual
Prefix:DR
First Name:THOMPSON
Middle Name:JAMES
Last Name:KELLY
Suffix:JR
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 1:5901 GREEN VALLEY CIRCLE
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90230-6953
Mailing Address - Country:US
Mailing Address - Phone:310-258-4162
Mailing Address - Fax:
Practice Address - Street 1:5901 GREEN VALLEY CIRCLE
Practice Address - Street 2:
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90230-6953
Practice Address - Country:US
Practice Address - Phone:310-258-4162
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-07
Last Update Date:2011-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY20114103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY20114OtherPSYCHOLOGY