| Doctor Name: | KENNETH KELLY |
| NPI Number: | 1336364660 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | |
| License Number: | |
| Business Practice Address: | 1118 W Aztec Blvd Aztec, NM - 874101818 |
| Business Phone Number: | 5053343695 |
| Business Fax Number: | |
| Mailing Address: | 212 N Valley Blvd, BLOOMFIELD |
| State: | NM |
| Postal Code: | 874135749 |
| Phone Number: | 6029993618 |
| Fax Number: | |
| NPI Enumeration Date: | 04/13/2007 |
| NPI Last Update Date: | 08/18/2010 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 103TS0200X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | AZ |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Psychologist |
| Taxonomy Specialization: | School |
| Taxonomy Definition: | |