{
"Npi": {
"NPI": "1023404704",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "HENRY ALBERT KELLY JR",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": "6",
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "4124 FIRWOOD LN APT L",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "CHARLOTTE",
"MailingAddressStateName": "NC",
"MailingAddressPostalCode": "28209-2724",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "910-747-5215",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "4124 FIRWOOD LN APT L",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "CHARLOTTE",
"PracticeLocationAddressStateName": "NC",
"PracticeLocationAddressPostalCode": "28209-2724",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "910-747-5215",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "04/09/2015",
"LastUpdateDate": "04/09/2015",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "KELLY",
"AuthorizedOfficialFirstName": "HENRY",
"AuthorizedOfficialMiddleName": "ALBERT",
"AuthorizedOfficialTitle": "MHPA, PH.D",
"AuthorizedOfficialNamePrefix": "DR.",
"AuthorizedOfficialNameSuffix": "JR.",
"AuthorizedOfficialCredential": "MHPA, PH.D",
"AuthorizedOfficialTelephoneNumber": "910-747-5215",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "302R00000X",
"TaxonomyName": "Health Maintenance Organization",
"LicenseNumber": "1046352",
"LicenseNumberStateCode": "TN",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}