Provider Demographics
NPI:1215656327
Name:KELLEY, SCOTT
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:
Last Name:KELLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1333 S MAYFLOWER AVE STE 220
Mailing Address - Street 2:
Mailing Address - City:MONROVIA
Mailing Address - State:CA
Mailing Address - Zip Code:91016-5239
Mailing Address - Country:US
Mailing Address - Phone:260-440-0668
Mailing Address - Fax:
Practice Address - Street 1:201 E RUDISILL BLVD STE B100
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46806-1738
Practice Address - Country:US
Practice Address - Phone:260-255-3665
Practice Address - Fax:266-255-3594
Is Sole Proprietor?:No
Enumeration Date:2022-08-23
Last Update Date:2024-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician