Provider Demographics
NPI:1316536782
Name:HAGGERTY, KELLY (LMSW)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:HAGGERTY
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:137 ROCKLAND DR
Mailing Address - Street 2:
Mailing Address - City:NORTH SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13212-2701
Mailing Address - Country:US
Mailing Address - Phone:315-383-4143
Mailing Address - Fax:
Practice Address - Street 1:1045 JAMES ST STE 100
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13203-2758
Practice Address - Country:US
Practice Address - Phone:315-425-1004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-11
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
110276-01104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker