Provider Demographics
NPI:1104906395
Name:MONTELLA-JELLEY, SUSAN MARIE (LICSW)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:MARIE
Last Name:MONTELLA-JELLEY
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 1:101 HIGGINSON AVE STE 107D
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:RI
Mailing Address - Zip Code:02865-2734
Mailing Address - Country:US
Mailing Address - Phone:508-369-8904
Mailing Address - Fax:
Practice Address - Street 1:101 HIGGINSON AVE STE 107D
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:RI
Practice Address - Zip Code:02865-2734
Practice Address - Country:US
Practice Address - Phone:508-369-8904
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2009-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIISW007261041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical