Provider Demographics
NPI:1679634448
Name:SHELLY, KATHLEEN ADELAIDE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:ADELAIDE
Last Name:SHELLY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MISS
Other - First Name:KATHLEEN
Other - Middle Name:ADELAIDE
Other - Last Name:SHELLY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LSW
Mailing Address - Street 1:1330 W 26TH ST
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16508-1402
Mailing Address - Country:US
Mailing Address - Phone:814-459-9300
Mailing Address - Fax:
Practice Address - Street 1:1330 W 26TH ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16508-1402
Practice Address - Country:US
Practice Address - Phone:814-451-2283
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2019-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0140471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical