Provider Demographics
NPI:1871841254
Name:BAKER, KELLY GOSSARD (LMHC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:GOSSARD
Last Name:BAKER
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:R
Other - Last Name:BAKER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:6838 E GENESEE ST STE E
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13066-1029
Mailing Address - Country:US
Mailing Address - Phone:315-430-7150
Mailing Address - Fax:
Practice Address - Street 1:6838 E GENESEE ST STE E
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NY
Practice Address - Zip Code:13066-1029
Practice Address - Country:US
Practice Address - Phone:315-430-7150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-16
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000882101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYBA1047OtherGROUP MEDICARE
1235184235OtherGROUP NPI
NY02994838OtherGROUP MEDICAID