Provider Demographics
NPI:1023141322
Name:DEAN, KELLY L (LCSW)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:L
Last Name:DEAN
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 1:11 KIM CT
Mailing Address - Street 2:
Mailing Address - City:CENTEREACH
Mailing Address - State:NY
Mailing Address - Zip Code:11720-2357
Mailing Address - Country:US
Mailing Address - Phone:631-585-1785
Mailing Address - Fax:
Practice Address - Street 1:456 WAVERLY AVE
Practice Address - Street 2:
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-1586
Practice Address - Country:US
Practice Address - Phone:631-447-6460
Practice Address - Fax:631-289-7098
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2009-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY076258-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical