Healthcare Provider Details

I. General information

NPI: 1780477281
Provider Name (Legal Business Name): LARRY THOMAS KELLEY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2025
Last Update Date: 09/04/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1450 N LAKE AVE
PASADENA CA
91104-2387
US

IV. Provider business mailing address

1450 N LAKE AVER
PASADENA CA
91104
US

V. Phone/Fax

Practice location:
  • Phone: 626-794-1161
  • Fax:
Mailing address:
  • Phone: 626-794-1161
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: