Provider Demographics
NPI:1740396522
Name:KELLY, MARIANNE K (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:MARIANNE
Middle Name:K
Last Name:KELLY
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 1:22 CRISSEY AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GENEVA
Mailing Address - State:IL
Mailing Address - Zip Code:60134-2351
Mailing Address - Country:US
Mailing Address - Phone:630-232-7770
Mailing Address - Fax:630-232-7773
Practice Address - Street 1:22 CRISSEY AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134-2351
Practice Address - Country:US
Practice Address - Phone:630-232-7770
Practice Address - Fax:630-232-7773
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2009-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490105341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK19759Medicare ID - Type Unspecified