Provider Demographics
NPI:1508064924
Name:KELLY, ROBERT CHARLES (LCSW)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:CHARLES
Last Name:KELLY
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:247 FARRAGUT AVE
Mailing Address - Street 2:
Mailing Address - City:HASTINGS ON HUDSON
Mailing Address - State:NY
Mailing Address - Zip Code:10706-3519
Mailing Address - Country:US
Mailing Address - Phone:914-963-6068
Mailing Address - Fax:
Practice Address - Street 1:984 N BROADWAY
Practice Address - Street 2:SUITE NUMBER 411
Practice Address - City:YONKERS
Practice Address - State:NY
Practice Address - Zip Code:10701-1318
Practice Address - Country:US
Practice Address - Phone:914-963-6068
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR026496-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY174852OtherMHN
NY02261521Medicaid
NYVALUE OPTIONSOther080064
NY0076246OtherGHI
NYNC0212Medicare ID - Type Unspecified