Healthcare Provider Details

I. General information

NPI: 1558467811
Provider Name (Legal Business Name): TIMOTHY PATRICK KELLY LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 02/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 WOODLAND AVE
PHILADELPHIA PA
19104-4551
US

IV. Provider business mailing address

2340 HIGH RD
HUNTINGDON VALLEY PA
19006-6512
US

V. Phone/Fax

Practice location:
  • Phone: 215-823-5800
  • Fax: 215-823-5919
Mailing address:
  • Phone: 215-823-5800
  • Fax: 215-823-5919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberPC001954
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberPC001954
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberPC001954
License Number StatePA
# 4
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License NumberPC001954
License Number StatePA
# 5
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberPC001954
License Number StatePA
# 6
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number01360
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: