Provider Demographics
NPI:1437598182
Name:KELLY, LISA M (MSW, LSW)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:KELLY
Suffix:
Gender:F
Credentials:MSW, LSW
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:M
Other - Last Name:HERALD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:521 BEALL AVE
Mailing Address - Street 2:
Mailing Address - City:WOOSTER
Mailing Address - State:OH
Mailing Address - Zip Code:44691-3589
Mailing Address - Country:US
Mailing Address - Phone:234-249-2189
Mailing Address - Fax:330-262-7836
Practice Address - Street 1:2708 CLEVELAND RD STE 200
Practice Address - Street 2:
Practice Address - City:WOOSTER
Practice Address - State:OH
Practice Address - Zip Code:44691-1703
Practice Address - Country:US
Practice Address - Phone:234-249-2189
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-17
Last Update Date:2023-07-21
Deactivation Date:2014-01-21
Deactivation Code:
Reactivation Date:2014-12-18
Provider Licenses
StateLicense IDTaxonomies
OH15024271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical