Provider Demographics
NPI:1629430749
Name:KOMICH, KELSEY ELIZABETH (LCSW)
Entity Type:Individual
Prefix:MISS
First Name:KELSEY
Middle Name:ELIZABETH
Last Name:KOMICH
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 1:77 WINDING WAY
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-6845
Mailing Address - Country:US
Mailing Address - Phone:207-632-8423
Mailing Address - Fax:
Practice Address - Street 1:269 UNION ST
Practice Address - Street 2:
Practice Address - City:LYNN
Practice Address - State:MA
Practice Address - Zip Code:01901-1314
Practice Address - Country:US
Practice Address - Phone:781-581-3900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-28
Last Update Date:2016-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALCSW 2216481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical