Healthcare Provider Details

I. General information

NPI: 1841049855
Provider Name (Legal Business Name): ADVANCED BEHAVIORAL WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2024
Last Update Date: 08/22/2026
Certification Date: 08/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5050I VILLAGE SQUARE DR
PADUCAH KY
42001-9499
US

IV. Provider business mailing address

5050I VILLAGE SQUARE DR
PADUCAH KY
42001-9499
US

V. Phone/Fax

Practice location:
  • Phone: 270-898-4044
  • Fax: 270-898-4045
Mailing address:
  • Phone: 270-898-4044
  • Fax: 270-898-4045

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: SAMUEL KELLEY MD
Title or Position: OWNER/CEO
Credential:
Phone: 617-877-8292