Provider Demographics
NPI:1992021521
Name:KELLEY, CYNTHIA J (LISW)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:J
Last Name:KELLEY
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 1:453 CERRILLOS RD
Mailing Address - Street 2:SUITE E
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87501-3784
Mailing Address - Country:US
Mailing Address - Phone:505-577-9657
Mailing Address - Fax:505-986-3826
Practice Address - Street 1:453 CERRILLOS RD
Practice Address - Street 2:SUITE E
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87501-3784
Practice Address - Country:US
Practice Address - Phone:505-577-9657
Practice Address - Fax:505-986-3826
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-07
Last Update Date:2010-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-072581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical