Provider Demographics
NPI:1932330693
Name:KELLY, STEVEN (LCSW)
Entity Type:Individual
Prefix:MR
First Name:STEVEN
Middle Name:
Last Name:KELLY
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2374 WEST 960 NORTH
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84601-1718
Mailing Address - Country:US
Mailing Address - Phone:435-671-7759
Mailing Address - Fax:
Practice Address - Street 1:151 S UNIVERSITY AVE # 1400
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601-4427
Practice Address - Country:US
Practice Address - Phone:801-851-7118
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-29
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7364059-3502104100000X
UT7364059-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT7364059-3502OtherCERTIFIED SOCIAL WORKER LICENSE