Provider Demographics
NPI:1326055690
Name:KELLY, JUDY (LCSW)
Entity Type:Individual
Prefix:
First Name:JUDY
Middle Name:
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 1:210 N HAMMES AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-6680
Mailing Address - Country:US
Mailing Address - Phone:815-725-6511
Mailing Address - Fax:815-725-7166
Practice Address - Street 1:210 N HAMMES AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-6680
Practice Address - Country:US
Practice Address - Phone:815-725-6511
Practice Address - Fax:815-725-7166
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490033131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL211727Medicare PIN