Provider Demographics
NPI:1518025683
Name:KELLY, CHARLES L (MSW, LICSW)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:L
Last Name:KELLY
Suffix:
Gender:M
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 396
Mailing Address - Street 2:
Mailing Address - City:BRANT ROCK
Mailing Address - State:MA
Mailing Address - Zip Code:02020-0396
Mailing Address - Country:US
Mailing Address - Phone:781-837-9312
Mailing Address - Fax:
Practice Address - Street 1:40 INDUSTRIAL PARK RD
Practice Address - Street 2:DEPARTMENT OF MENTAL HEALTH
Practice Address - City:PLYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02360-4884
Practice Address - Country:US
Practice Address - Phone:508-732-3011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1038591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAPO3270OtherBLUE SHEILD PROVIDER NUMB
MAPO3270Medicare ID - Type UnspecifiedPROVDER NUMBER