Provider Demographics
NPI:1649640764
Name:NICHOLS, KELLY HANNON (LCSW-R)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:HANNON
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:HANNON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW-R
Mailing Address - Street 1:215 DAWLEY RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13066-2546
Mailing Address - Country:US
Mailing Address - Phone:315-420-6293
Mailing Address - Fax:315-637-7576
Practice Address - Street 1:215 DAWLEY RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NY
Practice Address - Zip Code:13066-2546
Practice Address - Country:US
Practice Address - Phone:315-420-6293
Practice Address - Fax:315-637-7576
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-01
Last Update Date:2015-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY730704251041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical