Provider Demographics
NPI:1396856340
Name:ANTHONY, KELLY K (PHD)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:K
Last Name:ANTHONY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:5015 SOUTHPARK DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27713-7736
Mailing Address - Country:US
Mailing Address - Phone:919-794-5501
Mailing Address - Fax:919-794-5501
Practice Address - Street 1:5015 SOUTHPARK DR
Practice Address - Street 2:SUITE 200
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27713-7746
Practice Address - Country:US
Practice Address - Phone:919-794-5501
Practice Address - Fax:919-794-5501
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2012-01-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC3117103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6000837Medicaid
NC2822756Medicare PIN