Provider Demographics
NPI:1134241151
Name:KELLY, JAMES BRUCE (MED)
Entity type:Individual
Prefix:MR
First Name:JAMES
Middle Name:BRUCE
Last Name:KELLY
Suffix:
Gender:M
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25743 LUCKEY RD
Mailing Address - Street 2:
Mailing Address - City:PERRYSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43551-9754
Mailing Address - Country:US
Mailing Address - Phone:419-837-6356
Mailing Address - Fax:
Practice Address - Street 1:5757 MONCLOVA RD
Practice Address - Street 2:SUITE 16C
Practice Address - City:MAUMEE
Practice Address - State:OH
Practice Address - Zip Code:43537-1863
Practice Address - Country:US
Practice Address - Phone:419-893-0300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2430103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist