Provider Demographics
NPI:1134289515
Name:KELLEY, THOMAS H (LICSW)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:H
Last Name:KELLEY
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:64 ASPEN DR
Mailing Address - Street 2:
Mailing Address - City:ATKINSON
Mailing Address - State:NH
Mailing Address - Zip Code:03811-2715
Mailing Address - Country:US
Mailing Address - Phone:603-362-6073
Mailing Address - Fax:
Practice Address - Street 1:26 CHESTNUT ST
Practice Address - Street 2:2A
Practice Address - City:ANDOVER
Practice Address - State:MA
Practice Address - Zip Code:01810-3600
Practice Address - Country:US
Practice Address - Phone:978-470-3348
Practice Address - Fax:978-470-3767
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1027881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP02119Medicare ID - Type Unspecified