Provider Demographics
NPI:1619362134
Name:KELLEY, KELLY (LCSW)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:KELLEY
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 1:104 S FRONT AVE
Mailing Address - Street 2:
Mailing Address - City:PRESTONSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:41653-1614
Mailing Address - Country:US
Mailing Address - Phone:606-886-8572
Mailing Address - Fax:606-886-4433
Practice Address - Street 1:104 S FRONT AVE
Practice Address - Street 2:
Practice Address - City:PRESTONSBURG
Practice Address - State:KY
Practice Address - Zip Code:41653
Practice Address - Country:US
Practice Address - Phone:606-886-8572
Practice Address - Fax:606-886-4433
Is Sole Proprietor?:No
Enumeration Date:2015-04-01
Last Update Date:2018-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY37621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical