Provider Demographics
NPI:1740330992
Name:KELLY, KEVIN M (LCSW)
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:M
Last Name:KELLY
Suffix:
Gender:M
Credentials:LCSW
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Mailing Address - Street 1:951 NIAGARA STREET
Mailing Address - Street 2:DRUG & ALCOHOL ABUSE SERVICE PROGRAM
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14213
Mailing Address - Country:US
Mailing Address - Phone:716-883-5344
Mailing Address - Fax:716-884-1758
Practice Address - Street 1:951 NIAGARA STREET
Practice Address - Street 2:DRUG & ALCOHOL ABUSE SERVICE PROGRAM
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14213
Practice Address - Country:US
Practice Address - Phone:716-883-5344
Practice Address - Fax:716-884-1758
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2011-01-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY065920-1104100000X
NY078200-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker