Healthcare Provider Details

I. General information

NPI: 1023141322
Provider Name (Legal Business Name): KELLY L DEAN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 01/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

456 WAVERLY AVE
PATCHOGUE NY
11772-1586
US

IV. Provider business mailing address

11 KIM CT
CENTEREACH NY
11720-2357
US

V. Phone/Fax

Practice location:
  • Phone: 631-447-6460
  • Fax: 631-289-7098
Mailing address:
  • Phone: 631-585-1785
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number076258-1
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: