Provider Demographics
NPI:1780935809
Name:GACH, KELLY (LMSW)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:GACH
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 1:339 N BROADWAY
Mailing Address - Street 2:
Mailing Address - City:NYACK
Mailing Address - State:NY
Mailing Address - Zip Code:10960-1522
Mailing Address - Country:US
Mailing Address - Phone:845-358-7772
Mailing Address - Fax:
Practice Address - Street 1:339 N BROADWAY
Practice Address - Street 2:
Practice Address - City:NYACK
Practice Address - State:NY
Practice Address - Zip Code:10960-1522
Practice Address - Country:US
Practice Address - Phone:845-358-7772
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-28
Last Update Date:2012-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0779301041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool