Provider Demographics
NPI:1629393129
Name:KELLEY, TRESA (MHC MA)
Entity Type:Individual
Prefix:
First Name:TRESA
Middle Name:
Last Name:KELLEY
Suffix:
Gender:F
Credentials:MHC MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 SPRINGBROOK LN
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:PA
Mailing Address - Zip Code:17724-7858
Mailing Address - Country:US
Mailing Address - Phone:607-735-3564
Mailing Address - Fax:607-735-3569
Practice Address - Street 1:100 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:ELMIRA
Practice Address - State:NY
Practice Address - Zip Code:14901-2849
Practice Address - Country:US
Practice Address - Phone:607-735-3564
Practice Address - Fax:607-735-3569
Is Sole Proprietor?:No
Enumeration Date:2010-03-29
Last Update Date:2010-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002809101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health