Provider Demographics
NPI:1376201285
Name:LORETTA KELLY LCSW PC
Entity Type:Organization
Organization Name:LORETTA KELLY LCSW PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LORETTA
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:631-805-5668
Mailing Address - Street 1:250 BEACHVIEW ST
Mailing Address - Street 2:
Mailing Address - City:COPIAGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11726-3604
Mailing Address - Country:US
Mailing Address - Phone:631-805-5668
Mailing Address - Fax:
Practice Address - Street 1:250 BEACHVIEW ST
Practice Address - Street 2:
Practice Address - City:COPIAGUE
Practice Address - State:NY
Practice Address - Zip Code:11726-3604
Practice Address - Country:US
Practice Address - Phone:631-805-5668
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-08
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty