Provider Demographics
NPI:1144494485
Name:NEWBY, KELLY L
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:L
Last Name:NEWBY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2450 W RIDGE RD STE 303
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14626-3037
Mailing Address - Country:US
Mailing Address - Phone:585-448-0936
Mailing Address - Fax:585-448-0973
Practice Address - Street 1:2450 W RIDGE RD STE 303
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14626-3037
Practice Address - Country:US
Practice Address - Phone:585-448-0936
Practice Address - Fax:585-448-0973
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-17
Last Update Date:2019-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021789103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00357502Medicaid