Healthcare Provider Details

I. General information

NPI: 1477299717
Provider Name (Legal Business Name): KALYSSA RAINE OSGOOD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2022
Last Update Date: 05/10/2022
Certification Date: 05/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

779 EAST AVE APT 12
ROCHESTER NY
14607-2176
US

IV. Provider business mailing address

779 EAST AVE APT 12
ROCHESTER NY
14607-2176
US

V. Phone/Fax

Practice location:
  • Phone: 607-331-6021
  • Fax:
Mailing address:
  • Phone: 607-331-6021
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number2761916
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: