Provider Demographics
NPI:1023476249
Name:KELLY, EMILY
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 MAPLE AVE
Mailing Address - Street 2:1
Mailing Address - City:CORNWALL ON HUDSON
Mailing Address - State:NY
Mailing Address - Zip Code:12520-1501
Mailing Address - Country:US
Mailing Address - Phone:845-597-5347
Mailing Address - Fax:
Practice Address - Street 1:196 SARA LN
Practice Address - Street 2:
Practice Address - City:NEWBURGH
Practice Address - State:NY
Practice Address - Zip Code:12550-2597
Practice Address - Country:US
Practice Address - Phone:845-565-4345
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-02
Last Update Date:2016-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP00819252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency