Provider Demographics
NPI:1730726274
Name:BERARDI, KELLY
Entity type:Individual
Prefix:MS
First Name:KELLY
Middle Name:
Last Name:BERARDI
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 1:186 OAKLEY AVE
Mailing Address - Street 2:
Mailing Address - City:ELMONT
Mailing Address - State:NY
Mailing Address - Zip Code:11003-2520
Mailing Address - Country:US
Mailing Address - Phone:516-567-7796
Mailing Address - Fax:
Practice Address - Street 1:1000 ROSEDALE RD
Practice Address - Street 2:
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11581-2703
Practice Address - Country:US
Practice Address - Phone:516-224-0240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-03
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1719606103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1719606OtherEDUCATION