Kelly Ann Waller, LMHC

Primary specialty

Mental Health CounselorTaxonomy code 101YM0800X

License

011709 Issued in NY

Practice address

54 Chicago Ave
Massapequa, NY 11758-4422

Phone

(516) 804-0448

NPI assigned

Nov 16, 2021

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1637020800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1637020800000",
    "number": "1972269652",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "304 N UTICA AVE",
            "city": "MASSAPEQUA",
            "state": "NY",
            "postal_code": "117582148",
            "telephone_number": "516-477-3203"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "54 CHICAGO AVE",
            "city": "MASSAPEQUA",
            "state": "NY",
            "postal_code": "117584422",
            "telephone_number": "516-804-0448"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "400 Sunrise Hwy",
            "address_purpose": "LOCATION",
            "city": "Amityville",
            "state": "NY",
            "postal_code": "117012508",
            "country_code": "US",
            "telephone_number": "631-264-4000",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "WALLER",
        "first_name": "KELLY",
        "middle_name": "ANN",
        "credential": "LMHC",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2021-11-16",
        "last_updated": "2021-11-16",
        "certification_date": "2021-11-16",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "101YM0800X",
            "taxonomy_group": "",
            "desc": "Counselor, Mental Health",
            "state": "NY",
            "license": "011709",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Mental Health Counselor in Massapequa, NY
• Providers in Massapequa, NY by specialty
• Mental Health Counselor in New York

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 16, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.