Healthcare Provider Details

I. General information

NPI: 1346172236
Provider Name (Legal Business Name): KELLY MARIE DEVINE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2026
Last Update Date: 06/02/2026
Certification Date: 06/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 RIVERSIDE DR
JOHNSON CITY NY
13790-2742
US

IV. Provider business mailing address

512 CENTRAL ST
ENDICOTT NY
13760-4903
US

V. Phone/Fax

Practice location:
  • Phone: 607-217-4170
  • Fax: 607-238-1765
Mailing address:
  • Phone: 607-341-1632
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number013595
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: