Provider Demographics
NPI:1972761195
Name:MENDONCA, KELLY ANN (PSYD)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:ANN
Last Name:MENDONCA
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:483 CLERMONT AVE
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11238-2253
Mailing Address - Country:US
Mailing Address - Phone:718-643-5300
Mailing Address - Fax:
Practice Address - Street 1:483 CLERMONT AVE
Practice Address - Street 2:3RD FLOOR
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11238-2253
Practice Address - Country:US
Practice Address - Phone:718-643-5300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-23
Last Update Date:2014-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001641-1101YM0800X
NYP92114103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health