Healthcare Provider Details

I. General information

NPI: 1073845210
Provider Name (Legal Business Name): KELLY ANNE SHANLEY LMHC, CASAC, MA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/12/2010
Last Update Date: 03/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 W 35TH ST
NEW YORK NY
10001-1701
US

IV. Provider business mailing address

19 W 34TH ST PH
NEW YORK NY
10001-3006
US

V. Phone/Fax

Practice location:
  • Phone: 212-736-5900
  • Fax: 212-643-1441
Mailing address:
  • Phone: 917-515-0200
  • Fax: 212-643-1441

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number22182
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number004658
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: