Provider Demographics
NPI:1295034643
Name:MACH, KELLY ANNE (MA)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:ANNE
Last Name:MACH
Suffix:
Gender:F
Credentials:MA
Other - Prefix:MS
Other - First Name:KELLY
Other - Middle Name:ANNE
Other - Last Name:BROGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:27 WINDSOR PL
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11215-5610
Mailing Address - Country:US
Mailing Address - Phone:718-514-1590
Mailing Address - Fax:
Practice Address - Street 1:497 6TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11215-4074
Practice Address - Country:US
Practice Address - Phone:718-577-2347
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-24
Last Update Date:2022-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
ORC4966101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program