Provider Demographics
NPI:1851718415
Name:GAY, KELLY J (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:J
Last Name:GAY
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1427 N 17TH ST
Mailing Address - Street 2:
Mailing Address - City:VINCENNES
Mailing Address - State:IN
Mailing Address - Zip Code:47591-5805
Mailing Address - Country:US
Mailing Address - Phone:812-316-2870
Mailing Address - Fax:
Practice Address - Street 1:1427 N 17TH ST
Practice Address - Street 2:
Practice Address - City:VINCENNES
Practice Address - State:IN
Practice Address - Zip Code:47591-5805
Practice Address - Country:US
Practice Address - Phone:812-316-2870
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-20
Last Update Date:2017-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0181491041C0700X
IN33006493A104100000X
IN34007146A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker