Provider Demographics
NPI:1881043958
Name:KELLY, SILAS W (LMSW)
Entity Type:Individual
Prefix:MR
First Name:SILAS
Middle Name:W
Last Name:KELLY
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:MR
Other - First Name:SILAS
Other - Middle Name:W
Other - Last Name:KELLY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMSW, CMHT
Mailing Address - Street 1:161 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-2879
Mailing Address - Country:US
Mailing Address - Phone:631-360-7578
Mailing Address - Fax:631-360-7687
Practice Address - Street 1:161 E MAIN ST
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-2879
Practice Address - Country:US
Practice Address - Phone:631-360-7578
Practice Address - Fax:631-360-7687
Is Sole Proprietor?:No
Enumeration Date:2016-06-08
Last Update Date:2016-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY095659101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)