Provider Demographics
NPI:1093210312
Name:KELLY, MARY BETH ELIZABETH (ACSW)
Entity Type:Individual
Prefix:MS
First Name:MARY BETH
Middle Name:ELIZABETH
Last Name:KELLY
Suffix:
Gender:F
Credentials:ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 RIVERSIDE DR APT 1707
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-4127
Mailing Address - Country:US
Mailing Address - Phone:917-613-3552
Mailing Address - Fax:
Practice Address - Street 1:310 RIVERSIDE DR APT 1707
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-4127
Practice Address - Country:US
Practice Address - Phone:917-613-3552
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-28
Last Update Date:2018-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYRD256751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical