Provider Demographics
NPI:1174596357
Name:KELLY, BRYAN ROBERT (PHD)
Entity type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:ROBERT
Last Name:KELLY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 GRAY BIRCH RD
Mailing Address - Street 2:
Mailing Address - City:EAST SANDWICH
Mailing Address - State:MA
Mailing Address - Zip Code:02537-1457
Mailing Address - Country:US
Mailing Address - Phone:508-833-9013
Mailing Address - Fax:
Practice Address - Street 1:3 GRAY BIRCH RD
Practice Address - Street 2:
Practice Address - City:EAST SANDWICH
Practice Address - State:MA
Practice Address - Zip Code:02537-1457
Practice Address - Country:US
Practice Address - Phone:508-833-9013
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3610103TC0700X
NH710103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical