Provider Demographics
NPI:1306617931
Name:SAMBROOK, KELLY JO (LCSW)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:JO
Last Name:SAMBROOK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:JO
Other - Last Name:MURPHY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW, LCSW
Mailing Address - Street 1:66 PARK RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:EAST GREENBUSH
Mailing Address - State:NY
Mailing Address - Zip Code:12061-3636
Mailing Address - Country:US
Mailing Address - Phone:518-441-7310
Mailing Address - Fax:
Practice Address - Street 1:73 COUNTY ROUTE 11A
Practice Address - Street 2:
Practice Address - City:CRARYVILLE
Practice Address - State:NY
Practice Address - Zip Code:12521-5510
Practice Address - Country:US
Practice Address - Phone:518-325-2800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-11
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0753211041C0700X, 1041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool