Provider Demographics
NPI:1144374620
Name:ARDIETA, KELLY C (LCSW-R)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:C
Last Name:ARDIETA
Suffix:
Gender:F
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 1:1344 UNIVERSITY AVE
Mailing Address - Street 2:SUITE 230
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14607-1656
Mailing Address - Country:US
Mailing Address - Phone:585-271-3090
Mailing Address - Fax:
Practice Address - Street 1:1344 UNIVERSITY AVE
Practice Address - Street 2:SUITE 230
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14607-1656
Practice Address - Country:US
Practice Address - Phone:585-271-3090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2013-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR043557-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical