Provider Demographics
NPI:1760936165
Name:HENRY, KELLY L (MSW, LISW-S)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:L
Last Name:HENRY
Suffix:
Gender:F
Credentials:MSW, LISW-S
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:BRANNON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LISW
Mailing Address - Street 1:PO BOX 165
Mailing Address - Street 2:
Mailing Address - City:NEW CONCORD
Mailing Address - State:OH
Mailing Address - Zip Code:43762-0165
Mailing Address - Country:US
Mailing Address - Phone:405-860-8817
Mailing Address - Fax:740-870-2631
Practice Address - Street 1:601 UNDERWOOD ST STE 106
Practice Address - Street 2:
Practice Address - City:ZANESVILLE
Practice Address - State:OH
Practice Address - Zip Code:43701-3771
Practice Address - Country:US
Practice Address - Phone:330-969-2104
Practice Address - Fax:740-870-2631
Is Sole Proprietor?:No
Enumeration Date:2016-08-15
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.17005481041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0242332Medicaid