Healthcare Provider Details

I. General information

NPI: 1740330992
Provider Name (Legal Business Name): KEVIN M KELLY LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/11/2007
Last Update Date: 01/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

951 NIAGARA STREET DRUG & ALCOHOL ABUSE SERVICE PROGRAM
BUFFALO NY
14213
US

IV. Provider business mailing address

951 NIAGARA STREET DRUG & ALCOHOL ABUSE SERVICE PROGRAM
BUFFALO NY
14213
US

V. Phone/Fax

Practice location:
  • Phone: 716-883-5344
  • Fax: 716-884-1758
Mailing address:
  • Phone: 716-883-5344
  • Fax: 716-884-1758

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number065920-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number078200-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: