Provider Demographics
NPI:1962559278
Name:KELLY, JERRY S (LCSW-R)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:S
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 1:525 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14203-1711
Mailing Address - Country:US
Mailing Address - Phone:716-856-4494
Mailing Address - Fax:716-842-1277
Practice Address - Street 1:3719 UNION RD
Practice Address - Street 2:
Practice Address - City:CHEEKTOWAGA
Practice Address - State:NY
Practice Address - Zip Code:14225-4249
Practice Address - Country:US
Practice Address - Phone:716-681-7394
Practice Address - Fax:716-685-9087
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000039611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00030241501OtherUNIVERA