Provider Demographics
NPI:1750500476
Name:KELLY, KRISTINA JENNIFER (LMHC)
Entity Type:Individual
Prefix:MRS
First Name:KRISTINA
Middle Name:JENNIFER
Last Name:KELLY
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:KRISTINA
Other - Middle Name:JENNIFER
Other - Last Name:PIERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMHC
Mailing Address - Street 1:ESSEX COUNTY MEMORIAL HEALTH
Mailing Address - Street 2:7513 COURT ST PO BOX 8
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:12932
Mailing Address - Country:US
Mailing Address - Phone:518-873-3670
Mailing Address - Fax:518-873-3777
Practice Address - Street 1:ESSEX COUNTY MEMORIAL HEALTH
Practice Address - Street 2:7513 COURT ST
Practice Address - City:ELIZABETHTOWN
Practice Address - State:NY
Practice Address - Zip Code:12932
Practice Address - Country:US
Practice Address - Phone:518-873-3670
Practice Address - Fax:518-873-3777
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0680134561101YM0800X
NY002069106H00000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02996789Medicaid