Provider Demographics
NPI:1619980992
Name:KELLY, GINNY LYNN (LICSW)
Entity Type:Individual
Prefix:
First Name:GINNY
Middle Name:LYNN
Last Name:KELLY
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 CHARLES ELDRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02347
Mailing Address - Country:US
Mailing Address - Phone:508-947-1683
Mailing Address - Fax:508-947-1684
Practice Address - Street 1:104 CHARLES ELDRIDGE DR
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:MA
Practice Address - Zip Code:02347
Practice Address - Country:US
Practice Address - Phone:508-947-1683
Practice Address - Fax:508-947-1684
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10288601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1890140Medicaid
P07349OtherBCBS
2023330OtherCIGNA
33106235301OtherPACIFICARE
349493OtherMAGELLAN
469030OtherTUFTS
159505OtherVALUE OPTIONS
410720OtherBLUE CHIP
469030OtherTUFTS