Provider Demographics
NPI:1205187788
Name:KELLY, SHANNON MARIE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:MARIE
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 1:1040 FLYNN RD
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93012-5092
Mailing Address - Country:US
Mailing Address - Phone:805-673-3930
Mailing Address - Fax:805-659-3217
Practice Address - Street 1:200 S WELLS RD STE 250
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93004-1383
Practice Address - Country:US
Practice Address - Phone:805-647-0991
Practice Address - Fax:805-647-7163
Is Sole Proprietor?:No
Enumeration Date:2012-09-25
Last Update Date:2019-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW75222104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker