Provider Demographics
NPI:1932501566
Name:KELLY, CAROL J (LISW-S)
Entity Type:Individual
Prefix:MRS
First Name:CAROL
Middle Name:J
Last Name:KELLY
Suffix:
Gender:F
Credentials:LISW-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:68 W CHURCH ST STE 318
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43055-5050
Mailing Address - Country:US
Mailing Address - Phone:740-281-1777
Mailing Address - Fax:740-281-1778
Practice Address - Street 1:68 W CHURCH ST STE 318
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-5050
Practice Address - Country:US
Practice Address - Phone:740-281-1777
Practice Address - Fax:740-281-1778
Is Sole Proprietor?:No
Enumeration Date:2014-09-26
Last Update Date:2016-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI99191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical