Provider Demographics
NPI:1952630048
Name:CONN, KELLY A (LISW)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:A
Last Name:CONN
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:67 TAFT ST
Mailing Address - Street 2:
Mailing Address - City:SHELBY
Mailing Address - State:OH
Mailing Address - Zip Code:44875-1430
Mailing Address - Country:US
Mailing Address - Phone:419-566-4555
Mailing Address - Fax:419-756-2594
Practice Address - Street 1:2458 STETZER RD
Practice Address - Street 2:
Practice Address - City:BUCYRUS
Practice Address - State:OH
Practice Address - Zip Code:44820-2066
Practice Address - Country:US
Practice Address - Phone:419-562-2000
Practice Address - Fax:419-562-1296
Is Sole Proprietor?:No
Enumeration Date:2009-12-18
Last Update Date:2013-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI09003621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical