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General NPI Number Information
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NPI Number | 1962584623
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Entity Type | Individual
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Provider Name | KEVIN JAMES KELLY PSY.D.
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Gender | Male
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Dates
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Enumeration Date | 10/20/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 10560 MAIN ST STE 411
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City | FAIRFAX
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State | VA
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Zip | 22030-7174
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Country | US
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Telephone | 703-855-3802
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Fax |
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Provider Business Mailing Address
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Address Line | 2251 PIMMIT DR APT 412
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City | FALLS CHURCH
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State | VA
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Zip | 22043-2813
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Country | US
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Telephone | 703-288-1138
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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 | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 0810002204
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License Number State | VA
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