Provider Demographics
NPI:1780898544
Name:KELLEY, DAVID MELVIN (PHD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:MELVIN
Last Name:KELLEY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4037 157TH ST
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11354-5045
Mailing Address - Country:US
Mailing Address - Phone:718-359-8215
Mailing Address - Fax:
Practice Address - Street 1:124 E 84TH ST
Practice Address - Street 2:SUITE 1D
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10028-0915
Practice Address - Country:US
Practice Address - Phone:212-744-2121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY4740103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical