Healthcare Provider Details

I. General information

NPI: 1073980157
Provider Name (Legal Business Name): DAVID KEGLEY LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2015
Last Update Date: 08/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

146 NORTH ST
AUBURN NY
13021-1831
US

IV. Provider business mailing address

311 WELLS AVE W
NORTH SYRACUSE NY
13212-2245
US

V. Phone/Fax

Practice location:
  • Phone: 315-253-0341
  • Fax:
Mailing address:
  • Phone: 315-253-1139
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number091627-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: