=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942894118
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CASSIE KELLY
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/26/2021
-----------------------------------------------------
Last Update Date | 02/26/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 67 MAGNOLIA AVE
-----------------------------------------------------
City | FLORAL PARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11001-2839
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-448-0775
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 67 MAGNOLIA AVE
-----------------------------------------------------
City | FLORAL PARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11001-2839
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-448-0775
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 221700000X
-----------------------------------------------------
Taxonomy Name | Art Therapist
-----------------------------------------------------
License Number | 002267
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------