Provider Demographics
NPI:1356191035
Name:KELLY, BENJAMIN (PRS)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:KELLY
Suffix:
Gender:M
Credentials:PRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:546 2ND ST APT 11
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:OH
Mailing Address - Zip Code:45662-3886
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9620 CAREYS RUN POND CREEK RD
Practice Address - Street 2:
Practice Address - City:MC DERMOTT
Practice Address - State:OH
Practice Address - Zip Code:45652-3902
Practice Address - Country:US
Practice Address - Phone:740-858-6683
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-25
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPS.004918175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist