Provider Demographics
NPI:1306519145
Name:KELLEY, NATHANIEL (LPC)
Entity type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:
Last Name:KELLEY
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:NATHAN
Other - Middle Name:
Other - Last Name:KELLEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPC
Mailing Address - Street 1:431 SPOTSWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23517-2110
Mailing Address - Country:US
Mailing Address - Phone:540-421-5001
Mailing Address - Fax:
Practice Address - Street 1:7460 CENTRAL BUSINESS PARK DR
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23513-2818
Practice Address - Country:US
Practice Address - Phone:540-421-5001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-28
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701010683101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0701010683OtherVA BOARD OF COUNSELING LICENSE NUMBER