Healthcare Provider Details

I. General information

NPI: 1043783251
Provider Name (Legal Business Name): AMBER M KELLY LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/10/2019
Last Update Date: 01/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

76 VETERANS AVE # 11630210
BATH NY
14810-0840
US

IV. Provider business mailing address

73 VETERANS AVE BH-116-30-210
BATH NY
14810
US

V. Phone/Fax

Practice location:
  • Phone: 607-664-4000
  • Fax: 607-664-4360
Mailing address:
  • Phone: 607-664-4000
  • Fax: 607-664-4360

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number103521
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: