Provider Demographics
NPI:1477030823
Name:KELLY, THOMAS JOHN (LADC)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:JOHN
Last Name:KELLY
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 BROOKSIDE DR
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04021-4057
Mailing Address - Country:US
Mailing Address - Phone:207-357-3774
Mailing Address - Fax:
Practice Address - Street 1:1 DELTA DR
Practice Address - Street 2:
Practice Address - City:WESTBROOK
Practice Address - State:ME
Practice Address - Zip Code:04092-4745
Practice Address - Country:US
Practice Address - Phone:207-853-7227
Practice Address - Fax:207-856-2112
Is Sole Proprietor?:No
Enumeration Date:2018-07-27
Last Update Date:2018-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC3444101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME207LA0401XMedicaid