Basic Information
| Provider Information | |||||||||
| NPI: | 1033473723 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLY | ||||||||
| FirstName: | EILEEN | ||||||||
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| Credential: | MA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19 JEFFERSON AVE | ||||||||
| Address2: | |||||||||
| City: | MASSAPEQUA PARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117622613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5167988681 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 47 HUMPHREY DR | ||||||||
| Address2: | |||||||||
| City: | SYOSSET | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117914022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5169217171 | ||||||||
| FaxNumber: | 5169218130 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2012 | ||||||||
| LastUpdateDate: | 06/27/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 252Y00000X | 5111 | NY | Y | Agencies | Early Intervention Provider Agency |
No ID Information.