Healthcare Provider Details

I. General information

NPI: 1376542639
Provider Name (Legal Business Name): MICHAEL R. KELLEY PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/19/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10506 BURT CIR
OMAHA NE
68114-2094
US

IV. Provider business mailing address

10506 BURT CIR
OMAHA NE
68114-2094
US

V. Phone/Fax

Practice location:
  • Phone: 402-493-4444
  • Fax:
Mailing address:
  • Phone: 402-493-4444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number34
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: