Provider Demographics
NPI:1750436457
Name:KELLY, LAURENCE MERRILL JR (MED, PSYD)
Entity type:Individual
Prefix:DR
First Name:LAURENCE
Middle Name:MERRILL
Last Name:KELLY
Suffix:JR
Gender:M
Credentials:MED, PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:81 GREEN ST
Mailing Address - Street 2:APT. 2
Mailing Address - City:READING
Mailing Address - State:MA
Mailing Address - Zip Code:01867-3210
Mailing Address - Country:US
Mailing Address - Phone:603-714-4771
Mailing Address - Fax:
Practice Address - Street 1:11 UNION ST
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:MA
Practice Address - Zip Code:01840-1815
Practice Address - Country:US
Practice Address - Phone:978-685-1337
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
NH101YS0200X
MA9422103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool