Provider Demographics
NPI:1932745361
Name:KELLEY, JOHN-SCOTT B (MS, LAC)
Entity Type:Individual
Prefix:
First Name:JOHN-SCOTT
Middle Name:B
Last Name:KELLEY
Suffix:
Gender:M
Credentials:MS, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2153 E JOYCE BLVD STE 201
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-5285
Mailing Address - Country:US
Mailing Address - Phone:479-575-9471
Mailing Address - Fax:479-587-9392
Practice Address - Street 1:3715 N BUSINESS DR STE 104
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-5287
Practice Address - Country:US
Practice Address - Phone:479-521-1532
Practice Address - Fax:479-521-9940
Is Sole Proprietor?:No
Enumeration Date:2019-11-20
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA1912187101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR242832795Medicaid