Healthcare Provider Details

I. General information

NPI: 1548829880
Provider Name (Legal Business Name): KELLY COULEHAN CROTTY PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2019
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 SMITH HAVEN MALL STE 107
LAKE GROVE NY
11755-1219
US

IV. Provider business mailing address

4 SMITH HAVEN MALL STE 107
LAKE GROVE NY
11755-1219
US

V. Phone/Fax

Practice location:
  • Phone: 646-580-5107
  • Fax:
Mailing address:
  • Phone: 646-580-5107
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number022496-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: