=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154621480
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRIEN SHARP KELLEY PH.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/03/2010
-----------------------------------------------------
Last Update Date | 11/03/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 817 BROADWAY 10TH FLOOR
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10003-4709
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-443-9643
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 86 W 12TH ST APT. 3E
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10011-8651
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-443-9643
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 018218
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------