Provider Demographics
NPI:1013907872
Name:THORP WOLCOTT, KELLEY M (LCSWR)
Entity Type:Individual
Prefix:MRS
First Name:KELLEY
Middle Name:M
Last Name:THORP WOLCOTT
Suffix:
Gender:F
Credentials:LCSWR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1231 GREEN ST
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13502-3946
Mailing Address - Country:US
Mailing Address - Phone:315-797-0472
Mailing Address - Fax:315-797-6066
Practice Address - Street 1:1231 GREEN ST
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13502-3946
Practice Address - Country:US
Practice Address - Phone:315-797-0472
Practice Address - Fax:315-797-6066
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR058963-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02456733Medicaid
NY209825OtherEXCELLUS BCBS
NY7568623OtherAETNA
NY476596OtherVALUE OPTIONS PIN
NY361914OtherMVP PIN#
NY476596OtherVALUE OPTIONS PIN