Provider Demographics
NPI:1982640330
Name:KELLEY, GAHAN C (LCSW)
Entity Type:Individual
Prefix:MS
First Name:GAHAN
Middle Name:C
Last Name:KELLEY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 RIVERSIDE DRIVE
Mailing Address - Street 2:#10R
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23225
Mailing Address - Country:US
Mailing Address - Phone:804-837-7125
Mailing Address - Fax:
Practice Address - Street 1:2000 RIVERSIDE DRIVE
Practice Address - Street 2:#10R
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23225
Practice Address - Country:US
Practice Address - Phone:804-837-7125
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-22
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040058591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA4945280Medicaid
VA080082MOtherSENTARA
VA145396OtherANTHEM
VA080082MOtherSENTARA