Healthcare Provider Details

I. General information

NPI: 1336312974
Provider Name (Legal Business Name): MR. THOMAS MARK KELLY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2008
Last Update Date: 04/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 HOLLAND AVE
BRADDOCK PA
15104-1599
US

IV. Provider business mailing address

400 HOLLAND AVE
BRADDOCK PA
15104-1599
US

V. Phone/Fax

Practice location:
  • Phone: 412-636-5151
  • Fax: 412-636-5705
Mailing address:
  • Phone: 412-636-5151
  • Fax: 412-636-5705

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: