Provider Demographics
NPI:1760744981
Name:FLYNN, KELLY ANN (MA,MFT)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:ANN
Last Name:FLYNN
Suffix:
Gender:F
Credentials:MA,MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:191 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:AMITYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11701-2790
Mailing Address - Country:US
Mailing Address - Phone:631-264-0058
Mailing Address - Fax:631-264-0056
Practice Address - Street 1:191 BROADWAY
Practice Address - Street 2:
Practice Address - City:AMITYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11701-2790
Practice Address - Country:US
Practice Address - Phone:631-264-0058
Practice Address - Fax:631-264-0056
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-13
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP83005101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health