Provider Demographics
NPI:1508013103
Name:KELLY, CHARLES J
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:J
Last Name:KELLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 150
Mailing Address - Street 2:
Mailing Address - City:GARRISON
Mailing Address - State:NY
Mailing Address - Zip Code:10524-0150
Mailing Address - Country:US
Mailing Address - Phone:845-335-1000
Mailing Address - Fax:
Practice Address - Street 1:21 FRANCISCAN WAY
Practice Address - Street 2:
Practice Address - City:GARRISON
Practice Address - State:NY
Practice Address - Zip Code:10524-0150
Practice Address - Country:US
Practice Address - Phone:845-335-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-26
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY20821101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)