Active NPI
Kevin James Kelly, PSY.D.
- Clinical Psychologist
- Fairfax, VA
National Provider Identifier
1962584623
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Clinical Psychologist
- License
- 0810002204
- Practice address
- 10560 Main St Ste 411
Fairfax, VA 22030-7174 - Phone
- (703) 855-3802
- NPI assigned
- Oct 20, 2006
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Clinical Psychologist | 103TC0700X | 0810002204 | VA | Primary |
Addresses
Primary practice location
10560 Main St Ste 411
Fairfax, VA 22030-7174
Mailing address
2251 Pimmit Dr Apt 412
Falls Church, VA 22043-2813
Phone (703) 288-1138
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in CO
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: No
- Power mobility devices: No
- Hospice: No
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20080125000474 | CO | Practitioner - Clinical Psychologist | 1456433796 | Practice locations: Boulder, CO |
Care Compare profile
Medicare Care Compare- Specialty
- Clinical Psychologist
- Education
- Other, 1993
- Medicare assignment
- Accepts the Medicare-approved amount as payment in full
Practice addresses (Care Compare)
2030 Floral Dr
Boulder, CO 80304-2738
Phone (720) 270-4716
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 0810002204 | VA | MD | Clinical Psychologist |
| 5795 | NC | MD | General Practice Dentistry |
| 3143 | CO | MD | Medical Physician Assistant |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1161302400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183852800000",
"number": "1962584623",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "2251 PIMMIT DR APT 412",
"city": "FALLS CHURCH",
"state": "VA",
"postal_code": "220432813",
"telephone_number": "703-288-1138"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "10560 MAIN ST STE 411",
"city": "FAIRFAX",
"state": "VA",
"postal_code": "220307174",
"telephone_number": "703-855-3802"
}
],
"practiceLocations": [],
"basic": {
"last_name": "KELLY",
"first_name": "KEVIN",
"middle_name": "JAMES",
"name_prefix": "Dr.",
"credential": "PSY.D.",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2006-10-20",
"last_updated": "2007-07-08",
"status": "A"
},
"taxonomies": [
{
"code": "103TC0700X",
"taxonomy_group": "",
"desc": "Psychologist, Clinical",
"state": "VA",
"license": "0810002204",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Fairfax, VA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.