Provider Demographics
NPI:1861248494
Name:CARPENTER, KELLY JENNILEE (CASAC-T)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:JENNILEE
Last Name:CARPENTER
Suffix:
Gender:F
Credentials:CASAC-T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6298 INDUCON DR E # SANBORNN
Mailing Address - Street 2:
Mailing Address - City:SANBORN
Mailing Address - State:NY
Mailing Address - Zip Code:14132-9013
Mailing Address - Country:US
Mailing Address - Phone:716-201-8312
Mailing Address - Fax:
Practice Address - Street 1:6298 INDUCON DR E # SANBORNN
Practice Address - Street 2:
Practice Address - City:SANBORN
Practice Address - State:NY
Practice Address - Zip Code:14132-9013
Practice Address - Country:US
Practice Address - Phone:716-219-8700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-25
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
NY101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)