Provider Demographics
NPI:1437383262
Name:KELLY, CERESE (LCSW)
Entity Type:Individual
Prefix:
First Name:CERESE
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:CALVIA
Other - Middle Name:CERESE
Other - Last Name:MOSHER-KELLY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:1969 W OGDEN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3765
Mailing Address - Country:US
Mailing Address - Phone:312-864-7845
Mailing Address - Fax:312-864-9141
Practice Address - Street 1:1969 W OGDEN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3765
Practice Address - Country:US
Practice Address - Phone:312-864-7845
Practice Address - Fax:412-864-9141
Is Sole Proprietor?:No
Enumeration Date:2009-05-07
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0083841041C0700X
IL1490083841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical