Healthcare Provider Details

I. General information

NPI: 1962559278
Provider Name (Legal Business Name): JERRY S KELLY LCSW-R
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3719 UNION RD
CHEEKTOWAGA NY
14225-4249
US

IV. Provider business mailing address

525 WASHINGTON ST
BUFFALO NY
14203-1711
US

V. Phone/Fax

Practice location:
  • Phone: 716-681-7394
  • Fax: 716-685-9087
Mailing address:
  • Phone: 716-856-4494
  • Fax: 716-842-1277

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number00003961
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: