Provider Demographics
NPI:1861441297
Name:SMITH, KELLY SANDRA (LCSW-R)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:SANDRA
Last Name:SMITH
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3779 STATE ROUTE 14A
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:NY
Mailing Address - Zip Code:14456-9103
Mailing Address - Country:US
Mailing Address - Phone:315-781-0413
Mailing Address - Fax:
Practice Address - Street 1:216 HAMILTON ST
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:NY
Practice Address - Zip Code:14456-2911
Practice Address - Country:US
Practice Address - Phone:315-730-5306
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-10
Last Update Date:2017-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR054827-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYCC4827Medicare ID - Type Unspecified