Provider Demographics
NPI:1639643505
Name:VOLLMER, KELLY (LMHC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:VOLLMER
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:567 CENTER DYRE AVENUE
Mailing Address - Street 2:
Mailing Address - City:WEST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11795
Mailing Address - Country:US
Mailing Address - Phone:631-813-5306
Mailing Address - Fax:
Practice Address - Street 1:435 MAIN STREET
Practice Address - Street 2:SUITE 5
Practice Address - City:ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11730
Practice Address - Country:US
Practice Address - Phone:631-664-1582
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-14
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008209101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health