Basic Information
| Provider Information | |||||||||
| NPI: | 1962559278 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLY | ||||||||
| FirstName: | JERRY | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | LCSW-R | ||||||||
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| Mailing Information | |||||||||
| Address1: | 525 WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142031711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168564494 | ||||||||
| FaxNumber: | 7168421277 | ||||||||
| Practice Location | |||||||||
| Address1: | 3719 UNION RD | ||||||||
| Address2: | |||||||||
| City: | CHEEKTOWAGA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142254249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166817394 | ||||||||
| FaxNumber: | 7166859087 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 00003961 | NY | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 00030241501 | 01 | NY | UNIVERA | OTHER |