Provider Demographics
NPI:1497180376
Name:BIEBER, KELLY (MA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:BIEBER
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:CRANDALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:457 18TH ST
Mailing Address - Street 2:
Mailing Address - City:WEST BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11704-2201
Mailing Address - Country:US
Mailing Address - Phone:631-236-7644
Mailing Address - Fax:
Practice Address - Street 1:15645 84TH ST
Practice Address - Street 2:
Practice Address - City:HOWARD BEACH
Practice Address - State:NY
Practice Address - Zip Code:11414-2645
Practice Address - Country:US
Practice Address - Phone:718-738-1800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-10
Last Update Date:2013-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency