Provider Demographics
NPI:1114099082
Name:KELLY, KATHLEEN MARY (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:MARY
Last Name:KELLY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:5855 E NAPLES PLZ
Mailing Address - Street 2:STE 210
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90803-5080
Mailing Address - Country:US
Mailing Address - Phone:562-987-3335
Mailing Address - Fax:562-930-1095
Practice Address - Street 1:5855 E NAPLES PLZ
Practice Address - Street 2:STE 210
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90803-5080
Practice Address - Country:US
Practice Address - Phone:562-987-3335
Practice Address - Fax:562-930-1095
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS136481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical