Provider Demographics
NPI:1770948036
Name:SPENCE, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:SPENCE
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 1:98 N 2ND ST
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:NY
Mailing Address - Zip Code:13069-1254
Mailing Address - Country:US
Mailing Address - Phone:315-326-3555
Mailing Address - Fax:
Practice Address - Street 1:98 N 2ND ST
Practice Address - Street 2:
Practice Address - City:FULTON
Practice Address - State:NY
Practice Address - Zip Code:13069-1254
Practice Address - Country:US
Practice Address - Phone:315-326-3555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-30
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006979101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health