1770131245 NPI number — GEORGE WASHINGTON KELLY MA, LPC

Table of content: GEORGE WASHINGTON KELLY MA, LPC (NPI 1770131245)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770131245 NPI number — GEORGE WASHINGTON KELLY MA, LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KELLY
Provider First Name:
GEORGE
Provider Middle Name:
WASHINGTON
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MA, LPC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1770131245
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/19/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4560 E BROADWAY BLVD STE 223
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TUCSON
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85711-3558
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
520-261-0608
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
40 N SWAN RD STE 114
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TUCSON
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85711-3019
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-261-0608
Provider Business Practice Location Address Fax Number:
520-422-4911
Provider Enumeration Date:
08/28/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  LPC-18503 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 101Y00000X , with the licence number: LAC-16292 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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