Provider Demographics
NPI:1104170935
Name:KELLEY, BRIAN W (PSYD)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:W
Last Name:KELLEY
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:91-2135 FORT WEAVER RD
Mailing Address - Street 2:SUITE 501
Mailing Address - City:EWA BEACH
Mailing Address - State:HI
Mailing Address - Zip Code:96706-1940
Mailing Address - Country:US
Mailing Address - Phone:808-312-6800
Mailing Address - Fax:808-680-0006
Practice Address - Street 1:91-2135 FORT WEAVER RD
Practice Address - Street 2:SUITE 501
Practice Address - City:EWA BEACH
Practice Address - State:HI
Practice Address - Zip Code:96706-1940
Practice Address - Country:US
Practice Address - Phone:808-312-6800
Practice Address - Fax:808-680-0006
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-31
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI1353103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical