Provider Demographics
NPI:1447667878
Name:KELLY-SNOW, KRISTINA BETH (MS IN MENTAL HEALTH)
Entity type:Individual
Prefix:
First Name:KRISTINA
Middle Name:BETH
Last Name:KELLY-SNOW
Suffix:
Gender:F
Credentials:MS IN MENTAL HEALTH
Other - Prefix:
Other - First Name:KRISTINA
Other - Middle Name:BETH
Other - Last Name:KELLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:80 STATE HIGHWAY 310, SUITE 1
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:NY
Mailing Address - Zip Code:13617
Mailing Address - Country:US
Mailing Address - Phone:315-386-2167
Mailing Address - Fax:
Practice Address - Street 1:80 STATE HIGHWAY 310 STE 1
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:NY
Practice Address - Zip Code:13617-1436
Practice Address - Country:US
Practice Address - Phone:315-386-2167
Practice Address - Fax:315-268-0200
Is Sole Proprietor?:No
Enumeration Date:2014-07-17
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP93595101YM0800X
NY0071611101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health