Provider Demographics
NPI:1740934207
Name:KELLY, JAMES JOSEPH IV
Entity type:Individual
Prefix:MR
First Name:JAMES
Middle Name:JOSEPH
Last Name:KELLY
Suffix:IV
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12463 HADRIANS CT
Mailing Address - Street 2:
Mailing Address - City:BRISTOW
Mailing Address - State:VA
Mailing Address - Zip Code:20136-3074
Mailing Address - Country:US
Mailing Address - Phone:267-825-3645
Mailing Address - Fax:
Practice Address - Street 1:11835 HAZEL CIRCLE DR
Practice Address - Street 2:
Practice Address - City:BRISTOW
Practice Address - State:VA
Practice Address - Zip Code:20136-1223
Practice Address - Country:US
Practice Address - Phone:703-636-5104
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-03
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701011158101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional