Provider Demographics
NPI:1871502385
Name:PERRY, KELLY A (LCSW)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:A
Last Name:PERRY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:A
Other - Last Name:MCLEAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW-CC
Mailing Address - Street 1:PO BOX 259
Mailing Address - Street 2:
Mailing Address - City:SPRINGVALE
Mailing Address - State:ME
Mailing Address - Zip Code:04083-0259
Mailing Address - Country:US
Mailing Address - Phone:207-718-7084
Mailing Address - Fax:
Practice Address - Street 1:5 HEIDI ST
Practice Address - Street 2:
Practice Address - City:SPRINGVALE
Practice Address - State:ME
Practice Address - Zip Code:04083-1869
Practice Address - Country:US
Practice Address - Phone:207-718-7084
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMC10603104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME329230099Medicaid