Provider Demographics
NPI:1083677603
Name:PRATTICO, KELLY A (LMSW)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:A
Last Name:PRATTICO
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 WASHINGTON ST
Mailing Address - Street 2:MANAGED CARE DEPT.
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14203-1711
Mailing Address - Country:US
Mailing Address - Phone:716-856-4494
Mailing Address - Fax:716-842-1277
Practice Address - Street 1:25 LIBERTY ST
Practice Address - Street 2:SUITE 7
Practice Address - City:BATAVIA
Practice Address - State:NY
Practice Address - Zip Code:14020-3246
Practice Address - Country:US
Practice Address - Phone:585-343-0614
Practice Address - Fax:585-344-3868
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND00067217104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY160743251-40OtherPRISM
NY00030241501OtherUNIVERA
NY11520AMedicare ID - Type Unspecified