Provider Demographics
NPI:1144425661
Name:KELLY, HEATHER M (LCSW)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:M
Last Name:KELLY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:523 5TH ST
Mailing Address - Street 2:2L
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11215-3569
Mailing Address - Country:US
Mailing Address - Phone:917-971-5598
Mailing Address - Fax:
Practice Address - Street 1:583 5TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11215-3503
Practice Address - Country:US
Practice Address - Phone:917-971-5598
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR054247-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical