Provider Demographics
NPI:1770009193
Name:KELLEY, ELIZABETH
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:KELLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:
Other - Last Name:DANIELS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1287
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MA
Mailing Address - Zip Code:01083-1287
Mailing Address - Country:US
Mailing Address - Phone:781-264-1205
Mailing Address - Fax:
Practice Address - Street 1:421 N MAIN ST
Practice Address - Street 2:
Practice Address - City:LEEDS
Practice Address - State:MA
Practice Address - Zip Code:01053-9764
Practice Address - Country:US
Practice Address - Phone:413-584-4040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-17
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA224988104100000X
390200000X
MALICSW1265371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program