Provider Demographics
NPI:1457418451
Name:KELLY, LAURENCE MERRILL SR (EDD)
Entity Type:Individual
Prefix:DR
First Name:LAURENCE
Middle Name:MERRILL
Last Name:KELLY
Suffix:SR
Gender:M
Credentials:EDD
Other - Prefix:
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Mailing Address - Street 1:30 CANTON ST
Mailing Address - Street 2:SUITE 13
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03103-3524
Mailing Address - Country:US
Mailing Address - Phone:603-625-1670
Mailing Address - Fax:603-625-0335
Practice Address - Street 1:30 CANTON ST
Practice Address - Street 2:SUITE 13
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03103-3524
Practice Address - Country:US
Practice Address - Phone:603-625-1670
Practice Address - Fax:603-625-0335
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NHNH-659103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH80008144Medicaid
NH80008144Medicaid