Provider Demographics
NPI:1033314059
Name:KELLY, DALE (CSW)
Entity Type:Individual
Prefix:
First Name:DALE
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:CSW
Other - Prefix:
Other - First Name:DALE
Other - Middle Name:ANDERSON
Other - Last Name:KELLY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMSW
Mailing Address - Street 1:722 BRADLEY ST
Mailing Address - Street 2:
Mailing Address - City:MAMARONECK
Mailing Address - State:NY
Mailing Address - Zip Code:10543-1701
Mailing Address - Country:US
Mailing Address - Phone:914-450-7555
Mailing Address - Fax:
Practice Address - Street 1:722 BRADLEY ST
Practice Address - Street 2:
Practice Address - City:MAMARONECK
Practice Address - State:NY
Practice Address - Zip Code:10543-1701
Practice Address - Country:US
Practice Address - Phone:914-450-7555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-19
Last Update Date:2016-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY062781-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY037355FOtherMAGELLAN EMP BCBS
NY12076OtherBEACON
NY00868635Medicaid