Basic Information
| Provider Information | |||||||||
| NPI: | 1740330992 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLY | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 951 NIAGARA STREET | ||||||||
| Address2: | DRUG & ALCOHOL ABUSE SERVICE PROGRAM | ||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 14213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168835344 | ||||||||
| FaxNumber: | 7168841758 | ||||||||
| Practice Location | |||||||||
| Address1: | 951 NIAGARA STREET | ||||||||
| Address2: | DRUG & ALCOHOL ABUSE SERVICE PROGRAM | ||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 14213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168835344 | ||||||||
| FaxNumber: | 7168841758 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2007 | ||||||||
| LastUpdateDate: | 01/05/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 065920-1 | NY | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | 078200-1 | NY | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.