Provider Demographics
NPI:1215682059
Name:KELLEY, VONCEDRIC II
Entity type:Individual
Prefix:MR
First Name:VONCEDRIC
Middle Name:
Last Name:KELLEY
Suffix:II
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 1:6894 SLATE STONE WAY SE
Mailing Address - Street 2:
Mailing Address - City:MABLETON
Mailing Address - State:GA
Mailing Address - Zip Code:30126-5434
Mailing Address - Country:US
Mailing Address - Phone:240-440-5309
Mailing Address - Fax:
Practice Address - Street 1:115 N PARK TRL STE 123
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-7373
Practice Address - Country:US
Practice Address - Phone:866-610-0580
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-21
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician