Provider Demographics
NPI:1528208865
Name:MCCARTY, KELLY A (LISW, LADAC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:A
Last Name:MCCARTY
Suffix:
Gender:F
Credentials:LISW, LADAC
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 1846
Mailing Address - Street 2:230 ROTTEN TREE RD
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571-1846
Mailing Address - Country:US
Mailing Address - Phone:575-758-7824
Mailing Address - Fax:575-758-3346
Practice Address - Street 1:230 ROTTEN TREE RD
Practice Address - Street 2:230 ROTTEN TREE RD
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87574
Practice Address - Country:UM
Practice Address - Phone:575-758-7824
Practice Address - Fax:575-758-3346
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-26
Last Update Date:2009-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-067841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical