Provider Demographics
NPI:1427426063
Name:O'BRIEN, KELLY THERESA (LCSW)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:THERESA
Last Name:O'BRIEN
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 1:501 W MANCHESTER RD
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13219-2419
Mailing Address - Country:US
Mailing Address - Phone:315-325-8619
Mailing Address - Fax:315-201-2021
Practice Address - Street 1:365 SUMMERHAVEN DR N
Practice Address - Street 2:
Practice Address - City:EAST SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13057-3130
Practice Address - Country:US
Practice Address - Phone:315-325-8619
Practice Address - Fax:315-201-2021
Is Sole Proprietor?:No
Enumeration Date:2015-09-14
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY095134-011041C0700X
NY091228-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker