Provider Demographics
NPI:1184271785
Name:KELLY, EILEEN (LSW)
Entity type:Individual
Prefix:
First Name:EILEEN
Middle Name:
Last Name:KELLY
Suffix:
Gender:
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:336 BUTTERNUT FLTS
Mailing Address - Street 2:
Mailing Address - City:HONESDALE
Mailing Address - State:PA
Mailing Address - Zip Code:18431-3062
Mailing Address - Country:US
Mailing Address - Phone:570-647-7725
Mailing Address - Fax:
Practice Address - Street 1:1509 MAPLE ST
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18505-2707
Practice Address - Country:US
Practice Address - Phone:570-342-8305
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-20
Last Update Date:2025-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW136231104100000X
PACW0233311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA100759410-0048Medicaid
PA100759410-0018Medicaid