Provider Demographics
NPI:1699325043
Name:EUSTACE, KELLY
Entity type:Individual
Prefix:MS
First Name:KELLY
Middle Name:
Last Name:EUSTACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 LARCHMONT ACRES APT B
Mailing Address - Street 2:
Mailing Address - City:LARCHMONT
Mailing Address - State:NY
Mailing Address - Zip Code:10538-3369
Mailing Address - Country:US
Mailing Address - Phone:914-844-8448
Mailing Address - Fax:
Practice Address - Street 1:205 HUDSON ST FL 9
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10013-1810
Practice Address - Country:US
Practice Address - Phone:646-941-7645
Practice Address - Fax:929-596-7897
Is Sole Proprietor?:No
Enumeration Date:2019-09-18
Last Update Date:2024-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY0975401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program