Provider Demographics
NPI:1114449709
Name:THOMPSON, KELLY A (LICENSED MENTAL HEAL)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:A
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:LICENSED MENTAL HEAL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5800 BIG TREE ROAD
Mailing Address - Street 2:
Mailing Address - City:ORCHARD PARK
Mailing Address - State:NY
Mailing Address - Zip Code:14127
Mailing Address - Country:US
Mailing Address - Phone:716-662-7337
Mailing Address - Fax:716-662-0641
Practice Address - Street 1:5800 BIG TREE RD
Practice Address - Street 2:
Practice Address - City:ORCHARD PARK
Practice Address - State:NY
Practice Address - Zip Code:14127
Practice Address - Country:US
Practice Address - Phone:716-662-7337
Practice Address - Fax:716-662-0641
Is Sole Proprietor?:No
Enumeration Date:2017-07-14
Last Update Date:2017-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004737-1101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health