Provider Demographics
NPI:1083113807
Name:PURCELL, KELSEY
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:PURCELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3048
Mailing Address - Street 2:
Mailing Address - City:SHELTER ISLAND HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11965-3048
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2976 NORTHERN BLVD
Practice Address - Street 2:
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11101-2822
Practice Address - Country:US
Practice Address - Phone:347-510-3409
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-07
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY100782104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02740141Medicaid