MEDICARE: DR. BRYAN ROBERT KELLY PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	3610	MA
2	103TC0700X	Clinical Psychologist	710	NH

General Provider Information

NPI Number	:	1174596357
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRYAN ROBERT KELLY PH.D.

Provider Business Mailing Address
First Line	:	3 GRAY BIRCH RD
Second Line	:
City	:	EAST SANDWICH
State	:	MA
Zip	:	02537-1457
Country	:	US
Telephone Number	:	508-833-9013
Fax Number	:

Provider Business Practice Location Address
First Line	:	3 GRAY BIRCH RD
Second Line	:
City	:	EAST SANDWICH
State	:	MA
Zip	:	02537-1457
Country	:	US
Telephone Number	:	508-833-9013
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/09/2006
Last Update Date	:	07/08/2007

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