Provider Demographics
NPI:1336733179
Name:PETERSON, KELSEY E (LMSW)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:E
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 NORTHCREST AVE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14225-3433
Mailing Address - Country:US
Mailing Address - Phone:585-967-5553
Mailing Address - Fax:
Practice Address - Street 1:531 FARBER LAKES DR STE 201
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-5773
Practice Address - Country:US
Practice Address - Phone:716-632-5450
Practice Address - Fax:716-634-1098
Is Sole Proprietor?:No
Enumeration Date:2021-02-23
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY112017-011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical