Provider Demographics
NPI:1245721182
Name:COLEMAN, KELLY (PSYD)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:
Last Name:COLEMAN
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 1:115 ANGLE RD
Mailing Address - Street 2:
Mailing Address - City:WEST SENECA
Mailing Address - State:NY
Mailing Address - Zip Code:14224-4365
Mailing Address - Country:US
Mailing Address - Phone:716-432-3462
Mailing Address - Fax:
Practice Address - Street 1:162 MAIN ST
Practice Address - Street 2:
Practice Address - City:HAMBURG
Practice Address - State:NY
Practice Address - Zip Code:14075-4917
Practice Address - Country:US
Practice Address - Phone:716-371-1995
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-26
Last Update Date:2019-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023269103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist