Provider Demographics
NPI:1326652314
Name:HAVEN, KELSEY D
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:D
Last Name:HAVEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7992 PICKETT LN
Mailing Address - Street 2:
Mailing Address - City:CICERO
Mailing Address - State:NY
Mailing Address - Zip Code:13039-8670
Mailing Address - Country:US
Mailing Address - Phone:315-720-0303
Mailing Address - Fax:
Practice Address - Street 1:159 W 1ST ST
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:NY
Practice Address - Zip Code:13126-2045
Practice Address - Country:US
Practice Address - Phone:315-342-9575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-07
Last Update Date:2020-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024908225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist