Provider Demographics
NPI:1083925853
Name:KELLY, KATHLEEN KAREN (MA, MSW, LICSW)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:KAREN
Last Name:KELLY
Suffix:
Gender:F
Credentials:MA, MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5415 CONNECTICUT AVE NW
Mailing Address - Street 2:SUITE T-43
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20015-2765
Mailing Address - Country:US
Mailing Address - Phone:202-230-9307
Mailing Address - Fax:
Practice Address - Street 1:5415 CONNECTICUT AVE NW
Practice Address - Street 2:SUITE T-43
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20015-2765
Practice Address - Country:US
Practice Address - Phone:202-230-9307
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-28
Last Update Date:2012-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLC500788371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical