Healthcare Provider Details

I. General information

NPI: 1548392822
Provider Name (Legal Business Name): WILLIAM J. KELLY LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/12/2007
Last Update Date: 04/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 OAK TREE DR
N KINGSTOWN RI
02852-2035
US

IV. Provider business mailing address

22 OAK TREE DR
N KINGSTOWN RI
02852-2035
US

V. Phone/Fax

Practice location:
  • Phone: 401-885-2509
  • Fax:
Mailing address:
  • Phone: 401-885-2509
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number000455
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number93
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: