Provider Demographics
NPI:1811276611
Name:KELLY, SUZANNE D (LCSW)
Entity type:Individual
Prefix:MRS
First Name:SUZANNE
Middle Name:D
Last Name:KELLY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:323 MILL RD
Mailing Address - Street 2:
Mailing Address - City:WESTHAMPTON BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11978
Mailing Address - Country:US
Mailing Address - Phone:631-288-5131
Mailing Address - Fax:631-288-4296
Practice Address - Street 1:323 MILL RD
Practice Address - Street 2:
Practice Address - City:WESTHAMPTON BEACH
Practice Address - State:NY
Practice Address - Zip Code:11978
Practice Address - Country:US
Practice Address - Phone:631-288-5131
Practice Address - Fax:631-288-4296
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-10
Last Update Date:2011-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0386181041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical