Provider Demographics
NPI:1770131245
Name:KELLY, GEORGE WASHINGTON (MA, LPC)
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:WASHINGTON
Last Name:KELLY
Suffix:
Gender:M
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4560 E BROADWAY BLVD STE 223
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85711-3558
Mailing Address - Country:US
Mailing Address - Phone:520-261-0608
Mailing Address - Fax:
Practice Address - Street 1:40 N SWAN RD STE 114
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85711-3019
Practice Address - Country:US
Practice Address - Phone:520-261-0608
Practice Address - Fax:520-422-4911
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-28
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-18503101YP2500X
AZLAC-16292101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty