MEDICARE: DR. MARY S. KELLY PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	011605	NY

General Provider Information

NPI Number	:	1952453821
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARY S. KELLY PHD

Provider Business Mailing Address
First Line	:	1165 MORRIS PARK AVE
Second Line	:	2ND FLOOR
City	:	BRONX
State	:	NY
Zip	:	10461-1915
Country	:	US
Telephone Number	:	718-430-3908
Fax Number	:	718-430-3989

Provider Business Practice Location Address
First Line	:	1165 MORRIS PARK AVE
Second Line	:	2ND FLOOR
City	:	BRONX
State	:	NY
Zip	:	10461-1915
Country	:	US
Telephone Number	:	718-430-3908
Fax Number	:	718-430-3989

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/18/2007
Last Update Date	:	07/08/2007

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