Provider Demographics
NPI:1851621866
Name:KELLY, GINAMARIE (LCSW)
Entity Type:Individual
Prefix:MISS
First Name:GINAMARIE
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 LONG ISLAND AVE
Mailing Address - Street 2:
Mailing Address - City:YAPHANK
Mailing Address - State:NY
Mailing Address - Zip Code:11980-9639
Mailing Address - Country:US
Mailing Address - Phone:516-551-2324
Mailing Address - Fax:
Practice Address - Street 1:1329 BEACH CHANNEL DR
Practice Address - Street 2:
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11691-3211
Practice Address - Country:US
Practice Address - Phone:718-337-6800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-14
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY804041041C0700X
NY080264104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker