Provider Demographics
NPI:1073845210
Name:SHANLEY, KELLY ANNE (LMHC, CASAC, MA)
Entity type:Individual
Prefix:MS
First Name:KELLY
Middle Name:ANNE
Last Name:SHANLEY
Suffix:
Gender:F
Credentials:LMHC, CASAC, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 W 34TH ST PH
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10001-3006
Mailing Address - Country:US
Mailing Address - Phone:917-515-0200
Mailing Address - Fax:212-643-1441
Practice Address - Street 1:311 W 35TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-1701
Practice Address - Country:US
Practice Address - Phone:212-736-5900
Practice Address - Fax:212-643-1441
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-12
Last Update Date:2011-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY22182101YA0400X
NY004658101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)