Provider Demographics
NPI:1063087294
Name:KELLY, THOMAS P JR (PSYD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:P
Last Name:KELLY
Suffix:JR
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 1:5 CARL ST
Mailing Address - Street 2:
Mailing Address - City:LK RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-2311
Mailing Address - Country:US
Mailing Address - Phone:631-404-9844
Mailing Address - Fax:
Practice Address - Street 1:575 UNDERHILL BLVD
Practice Address - Street 2:
Practice Address - City:SYOSSET
Practice Address - State:NY
Practice Address - Zip Code:11791-3426
Practice Address - Country:US
Practice Address - Phone:631-404-9844
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-20
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP109603103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist