Provider Demographics
NPI:1942794151
Name:CANNAN, KELSEY KRUEGER (LMHC)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:KRUEGER
Last Name:CANNAN
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:KELSEY
Other - Middle Name:M
Other - Last Name:KRUEGER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMHC
Mailing Address - Street 1:21 GENTIAN WAY
Mailing Address - Street 2:
Mailing Address - City:FAIRPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14450-9210
Mailing Address - Country:US
Mailing Address - Phone:585-690-7501
Mailing Address - Fax:
Practice Address - Street 1:21 GENTIAN WAY
Practice Address - Street 2:
Practice Address - City:FAIRPORT
Practice Address - State:NY
Practice Address - Zip Code:14450-9210
Practice Address - Country:US
Practice Address - Phone:585-690-7501
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-20
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39004517A101YM0800X
NY010756101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health