Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 102L00000X | Psychologist | 2187 | OH |
N | 103T00000X | Psychologist | 2187 | OH |
N | 103TA0400X | Addiction Psychologist (Substance Use Disorder) | 2187 | OH |
Y | 103TC1900X | Counseling Psychologist | 2187 | OH |
N | 103TS0200X | School Psychologist | 2187 | OH |
NPI | 1013028653 |
---|---|
Provider Name | Dr. Gary Bernard Kelley |
First Address | Solon, OH 44139-8662 |
Second Address | Solon, OH 44139-3100 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 31/08/2006 |
Last Update Date | 25/10/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0320996 | (05) | OH |