Provider Demographics
NPI:1023404704
Name:HENRY ALBERT KELLY JR
Entity type:Organization
Organization Name:HENRY ALBERT KELLY JR
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MHPA, PH.D
Authorized Official - Prefix:DR
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:ALBERT
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:JR
Authorized Official - Credentials:MHPA, PHD
Authorized Official - Phone:910-747-5215
Mailing Address - Street 1:4124 FIRWOOD LN APT L
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209-2724
Mailing Address - Country:US
Mailing Address - Phone:910-747-5215
Mailing Address - Fax:
Practice Address - Street 1:4124 FIRWOOD LN APT L
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28209-2724
Practice Address - Country:US
Practice Address - Phone:910-747-5215
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-09
Last Update Date:2015-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1046352302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization