Provider Demographics
NPI:1982934816
Name:KELLY, PATRICK LOUJOHN SR (PHD)
Entity Type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:LOUJOHN
Last Name:KELLY
Suffix:SR
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:5540 E BROADWAY RD
Mailing Address - Street 2:SUITE 13
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-1440
Mailing Address - Country:US
Mailing Address - Phone:480-830-8299
Mailing Address - Fax:480-830-1820
Practice Address - Street 1:5540 E BROADWAY RD
Practice Address - Street 2:SUITE 13
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-1440
Practice Address - Country:US
Practice Address - Phone:480-830-8299
Practice Address - Fax:480-830-1820
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-25
Last Update Date:2009-12-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC-1448101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health