Provider Demographics
NPI:1477299717
Name:OSGOOD, KALYSSA RAINE
Entity Type:Individual
Prefix:
First Name:KALYSSA
Middle Name:RAINE
Last Name:OSGOOD
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 1:779 EAST AVE APT 12
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14607-2176
Mailing Address - Country:US
Mailing Address - Phone:607-331-6021
Mailing Address - Fax:
Practice Address - Street 1:779 EAST AVE APT 12
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14607-2176
Practice Address - Country:US
Practice Address - Phone:607-331-6021
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-10
Last Update Date:2022-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2761916103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY74275292200OtherFIDELIS