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General NPI Number Information
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NPI Number | 1083188643
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Entity Type | Individual
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Provider Name | MR. TIMOTHY KELLY SR.
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Gender | Male
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Dates
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Enumeration Date | 01/17/2019
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Last Update Date | 08/08/2024
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Provider Practice Location Address
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Address Line | 6200 ROCKSIDE WOODS BLVD N STE 305
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City | INDEPENDENCE
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State | OH
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Zip | 44131-2343
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Country | US
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Telephone | 234-410-5775
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Fax |
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Provider Business Mailing Address
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Address Line | 21231 WILMORE AVE
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City | EUCLID
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State | OH
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Zip | 44123-2823
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Country | US
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Telephone | 234-410-5775
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | CDCA.183151
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License Number State | OH
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Taxonomy #2
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | S.2202740-TRNE
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License Number State | OH
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Taxonomy #4
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Taxonomy Code | 175T00000X
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Taxonomy Name | Peer Specialist
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License Number |
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License Number State | OH
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Taxonomy #5
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Taxonomy Code | 171M00000X
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Taxonomy Name | Case Manager/Care Coordinator
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License Number |
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License Number State |
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