Provider Demographics
NPI:1285741439
Name:KELLY, WILLIAM A (LCSW-R)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:A
Last Name:KELLY
Suffix:
Gender:M
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:496 WHITE SPRUCE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14623-1608
Mailing Address - Country:US
Mailing Address - Phone:585-327-2121
Mailing Address - Fax:585-272-8986
Practice Address - Street 1:496 WHITE SPRUCE BLVD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14623-1608
Practice Address - Country:US
Practice Address - Phone:585-327-2121
Practice Address - Fax:585-272-8986
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0247461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY024746Medicaid