Provider Demographics
NPI:1053580506
Name:BROWN, KELLEY G (LCSW)
Entity type:Individual
Prefix:MRS
First Name:KELLEY
Middle Name:G
Last Name:BROWN
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 1:10 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CORTLAND
Mailing Address - State:NY
Mailing Address - Zip Code:13045-2130
Mailing Address - Country:US
Mailing Address - Phone:607-753-0234
Mailing Address - Fax:607-753-0286
Practice Address - Street 1:10 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CORTLAND
Practice Address - State:NY
Practice Address - Zip Code:13045-2130
Practice Address - Country:US
Practice Address - Phone:607-753-0234
Practice Address - Fax:607-753-0286
Is Sole Proprietor?:No
Enumeration Date:2008-02-28
Last Update Date:2013-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY076583101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01079267Medicaid