Provider Demographics
NPI:1932481678
Name:VAN DOLSON, KELLY LYNN (LICSW)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:LYNN
Last Name:VAN DOLSON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:789 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:NH
Mailing Address - Zip Code:03820-2526
Mailing Address - Country:US
Mailing Address - Phone:603-742-2263
Mailing Address - Fax:
Practice Address - Street 1:10 MEMBERS WAY STE 201
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:NH
Practice Address - Zip Code:03820-5933
Practice Address - Country:US
Practice Address - Phone:603-742-2263
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-19
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1197091041C0700X
NH21341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3117655Medicaid