Provider Demographics
NPI:1265128946
Name:SANCHEZ, KELLY CONRAD (LMFT)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:CONRAD
Last Name:SANCHEZ
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EAST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11730-2337
Mailing Address - Country:US
Mailing Address - Phone:631-666-1615
Mailing Address - Fax:
Practice Address - Street 1:1000 MAIN ST
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-2250
Practice Address - Country:US
Practice Address - Phone:631-296-1113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-14
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2091106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist