Provider Demographics
NPI:1467859686
Name:EGRESITS, KELLY (LCSWR)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:EGRESITS
Suffix:
Gender:F
Credentials:LCSWR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1427 GENESEE ST
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13501-4343
Mailing Address - Country:US
Mailing Address - Phone:315-738-1428
Mailing Address - Fax:
Practice Address - Street 1:1427 GENESEE ST
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13501-4343
Practice Address - Country:US
Practice Address - Phone:315-738-1428
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-03
Last Update Date:2016-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR047929-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04158421Medicaid
NYJ400196131Medicare PIN