Provider Demographics
NPI:1073664710
Name:KELLY, KATHLEEN LORRAINE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:LORRAINE
Last Name:KELLY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:460 MOUNT PLEASANT RD
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:FL
Mailing Address - Zip Code:32352-6301
Mailing Address - Country:US
Mailing Address - Phone:702-372-9237
Mailing Address - Fax:
Practice Address - Street 1:460 MOUNT PLEASANT RD
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:FL
Practice Address - Zip Code:32352-6301
Practice Address - Country:US
Practice Address - Phone:702-372-9237
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV2868C101YM0800X
NV2868-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health