Provider Demographics
NPI:1467477968
Name:KELLY, LORALEE S (MSW, LCSW, BCD)
Entity Type:Individual
Prefix:MS
First Name:LORALEE
Middle Name:S
Last Name:KELLY
Suffix:
Gender:F
Credentials:MSW, LCSW, BCD
Other - Prefix:MS
Other - First Name:LORI
Other - Middle Name:S
Other - Last Name:KELLY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSW, LCSW, BCD
Mailing Address - Street 1:PO BOX 63
Mailing Address - Street 2:6892 EAST VISTA BONITA
Mailing Address - City:PALOMINAS
Mailing Address - State:AZ
Mailing Address - Zip Code:85615-0063
Mailing Address - Country:US
Mailing Address - Phone:520-366-0070
Mailing Address - Fax:520-366-0038
Practice Address - Street 1:6892 E VISTA BONITA
Practice Address - Street 2:
Practice Address - City:PALOMINAS
Practice Address - State:AZ
Practice Address - Zip Code:85615-8510
Practice Address - Country:US
Practice Address - Phone:520-366-0070
Practice Address - Fax:520-366-0038
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW-106261041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical