Provider Demographics
NPI:1164660197
Name:WALKER ISHMAEL, KELLIE VICTORIA (PSYD)
Entity Type:Individual
Prefix:DR
First Name:KELLIE
Middle Name:VICTORIA
Last Name:WALKER ISHMAEL
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 FULLER RD
Mailing Address - Street 2:
Mailing Address - City:OSSINING
Mailing Address - State:NY
Mailing Address - Zip Code:10562-5607
Mailing Address - Country:US
Mailing Address - Phone:914-762-3826
Mailing Address - Fax:
Practice Address - Street 1:410 SAW MILL RIVER RD
Practice Address - Street 2:ARDSLEY PARK
Practice Address - City:ARDSLEY
Practice Address - State:NY
Practice Address - Zip Code:10502-2614
Practice Address - Country:US
Practice Address - Phone:914-479-0036
Practice Address - Fax:914-479-0037
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-29
Last Update Date:2009-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012185103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist