Provider Demographics
NPI:1790094654
Name:KIELY, JULIA B
Entity type:Individual
Prefix:DR
First Name:JULIA
Middle Name:B
Last Name:KIELY
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:JULIA
Other - Middle Name:N
Other - Last Name:BRODER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:16045 MAIN RD
Mailing Address - Street 2:
Mailing Address - City:MATTITUCK
Mailing Address - State:NY
Mailing Address - Zip Code:11952-2332
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:635 W 165TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-3724
Practice Address - Country:US
Practice Address - Phone:212-305-5977
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-27
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY021700103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program