Provider Demographics
NPI:1871236299
Name:IRVIN, KELSEY (PHD)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:IRVIN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:251 SALINA MEADOWS PARKWAY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13212
Mailing Address - Country:US
Mailing Address - Phone:315-464-2000
Mailing Address - Fax:315-464-2010
Practice Address - Street 1:713 HARRISON STREET
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210
Practice Address - Country:US
Practice Address - Phone:315-464-3149
Practice Address - Fax:315-464-3178
Is Sole Proprietor?:No
Enumeration Date:2022-04-14
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TC2200X
NY025862103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent