Provider Demographics
NPI:1730123795
Name:KELLY, KEVIN PATRICK (MSW)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:PATRICK
Last Name:KELLY
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:241 CLEVELAND AVE S
Mailing Address - Street 2:SUITE B3
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55105-1208
Mailing Address - Country:US
Mailing Address - Phone:651-698-2773
Mailing Address - Fax:651-698-2776
Practice Address - Street 1:241 CLEVELAND AVE S
Practice Address - Street 2:SUITE B3
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55105-1208
Practice Address - Country:US
Practice Address - Phone:651-698-2773
Practice Address - Fax:651-698-2776
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-16
Last Update Date:2009-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN132001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN62-76668OtherUNITED BEHAVIORAL HEALTH
MN502473100Medicaid
MN91G35KEOtherBLUE CROSS BLUE SHIELD