Provider Demographics
NPI:1487644266
Name:RHATIGAN, KELLY JEAN (PSYD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:JEAN
Last Name:RHATIGAN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1063 THOMAS AVE
Mailing Address - Street 2:
Mailing Address - City:BALDWIN
Mailing Address - State:NY
Mailing Address - Zip Code:11510-4134
Mailing Address - Country:US
Mailing Address - Phone:516-771-2106
Mailing Address - Fax:
Practice Address - Street 1:2277 GRAND AVE
Practice Address - Street 2:
Practice Address - City:BALDWIN
Practice Address - State:NY
Practice Address - Zip Code:11510-3148
Practice Address - Country:US
Practice Address - Phone:516-546-6924
Practice Address - Fax:516-546-9639
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0156081103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical