Provider Demographics
NPI:1790579225
Name:MANSER, KELLY (PHD)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:
Last Name:MANSER
Suffix:
Gender:
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:819 W 21ST ST STE 200
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23517-1539
Mailing Address - Country:US
Mailing Address - Phone:757-319-4650
Mailing Address - Fax:757-644-5065
Practice Address - Street 1:819 W 21ST ST STE 200
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23517-1539
Practice Address - Country:US
Practice Address - Phone:757-319-4650
Practice Address - Fax:757-644-5065
Is Sole Proprietor?:No
Enumeration Date:2025-04-08
Last Update Date:2025-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0805002531103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical