Provider Demographics
NPI:1043386246
Name:KELLY, SUSAN (LICSW)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 PECKS RD
Mailing Address - Street 2:
Mailing Address - City:PITTSFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01201-1339
Mailing Address - Country:US
Mailing Address - Phone:413-281-8984
Mailing Address - Fax:
Practice Address - Street 1:42 WENDELL AVENUE
Practice Address - Street 2:
Practice Address - City:PITTSFIELD
Practice Address - State:MA
Practice Address - Zip Code:01201
Practice Address - Country:US
Practice Address - Phone:413-281-8984
Practice Address - Fax:413-496-9116
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1115231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1855417Medicaid
MAP08627OtherBCBSMA
MAP23866Medicare ID - Type UnspecifiedMEDICARE