Provider Demographics
NPI:1053385369
Name:KELLY, DEBORAH MARIE (LCSW)
Entity type:Individual
Prefix:
First Name:DEBORAH
Middle Name:MARIE
Last Name:KELLY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 RIVERSIDE DR
Mailing Address - Street 2:6HW
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10023-2504
Mailing Address - Country:US
Mailing Address - Phone:212-580-3710
Mailing Address - Fax:
Practice Address - Street 1:ICD
Practice Address - Street 2:340 E 24 STREET
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-4019
Practice Address - Country:US
Practice Address - Phone:212-585-6282
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYRO410621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYNH6301Medicare ID - Type Unspecified