Provider Demographics
NPI:1841517695
Name:KELLEY, GREGORY VINCENT (RN, LPC)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:VINCENT
Last Name:KELLEY
Suffix:
Gender:M
Credentials:RN, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2410 PINE ST
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70125-4047
Mailing Address - Country:US
Mailing Address - Phone:504-430-5077
Mailing Address - Fax:
Practice Address - Street 1:3303 TULANE AVE
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70119-7185
Practice Address - Country:US
Practice Address - Phone:504-302-1323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-03
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA4637101YP2500X
TX64787101YP2500X
LA156751163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional