Provider Demographics
NPI:1144091992
Name:KELLEY, LYDIA (RBT)
Entity type:Individual
Prefix:
First Name:LYDIA
Middle Name:
Last Name:KELLEY
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 BROOKSTONE CT
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-1995
Mailing Address - Country:US
Mailing Address - Phone:703-470-3035
Mailing Address - Fax:
Practice Address - Street 1:1451 BELLE HAVEN RD STE 410
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22307-1201
Practice Address - Country:US
Practice Address - Phone:703-634-3532
Practice Address - Fax:571-495-2563
Is Sole Proprietor?:No
Enumeration Date:2024-01-10
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician