Provider Demographics
NPI:1033359864
Name:MARNIE KELLY-CROOK, INC.
Entity Type:Organization
Organization Name:MARNIE KELLY-CROOK, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARNIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:KELLY-CROOK
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW, MSW
Authorized Official - Phone:508-667-3133
Mailing Address - Street 1:54 EVERGREEN RD
Mailing Address - Street 2:
Mailing Address - City:NATICK
Mailing Address - State:MA
Mailing Address - Zip Code:01760-1636
Mailing Address - Country:US
Mailing Address - Phone:508-667-3133
Mailing Address - Fax:
Practice Address - Street 1:54 EVERGREEN RD
Practice Address - Street 2:
Practice Address - City:NATICK
Practice Address - State:MA
Practice Address - Zip Code:01760-1636
Practice Address - Country:US
Practice Address - Phone:508-667-3133
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-06
Last Update Date:2009-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1031867251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1265506976OtherINDIVIDUAL NPI#
MA1851403Medicaid
MAP21840OtherMEDICARE PROVIDER#
MA1031867OtherLICSW - LICENSE#
MAP07585OtherBLUE CROSS / BLUE SHIELD OF MASSACHUSETTS