Provider Demographics
NPI:1821397191
Name:KELLY, MONICA L (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MONICA
Middle Name:L
Last Name:KELLY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:13 RAILROAD SQUARE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:WATERVILLE
Mailing Address - State:ME
Mailing Address - Zip Code:04901-5255
Mailing Address - Country:US
Mailing Address - Phone:207-692-6649
Mailing Address - Fax:207-861-7012
Practice Address - Street 1:13 RAILROAD SQUARE
Practice Address - Street 2:SUITE 1
Practice Address - City:WATERVILLE
Practice Address - State:ME
Practice Address - Zip Code:04901-5255
Practice Address - Country:US
Practice Address - Phone:207-692-6649
Practice Address - Fax:207-861-7012
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-25
Last Update Date:2017-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC65071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1821397191Medicaid
MEE400203505Medicare UPIN