Provider Demographics
NPI:1518034842
Name:KELLY, ELAINE CLAIR (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:ELAINE
Middle Name:CLAIR
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 1:14931 REDCLIFF DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33625-1959
Mailing Address - Country:US
Mailing Address - Phone:813-961-5473
Mailing Address - Fax:813-961-8380
Practice Address - Street 1:104 E FOWLER AVE
Practice Address - Street 2:SUITE 140
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-5249
Practice Address - Country:US
Practice Address - Phone:813-961-5473
Practice Address - Fax:813-961-8380
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW31981041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ6021Medicare ID - Type UnspecifiedPART B