Provider Demographics
NPI:1902350978
Name:KELLY, RICHARD A (PSYD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:A
Last Name:KELLY
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4828 N NEENAH AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60656-4018
Mailing Address - Country:US
Mailing Address - Phone:773-350-9064
Mailing Address - Fax:773-341-1597
Practice Address - Street 1:477 E BUTTERFIELD RD
Practice Address - Street 2:
Practice Address - City:LOMBARD
Practice Address - State:IL
Practice Address - Zip Code:60148-5618
Practice Address - Country:US
Practice Address - Phone:773-234-2320
Practice Address - Fax:630-597-2583
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-08
Last Update Date:2016-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.010421101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional