Provider Demographics
NPI:1255403838
Name:KELLY, MAUREEN (MSW, LICSW)
Entity type:Individual
Prefix:
First Name:MAUREEN
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:977 SUMMIT AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55105-3032
Mailing Address - Country:US
Mailing Address - Phone:651-227-6369
Mailing Address - Fax:
Practice Address - Street 1:977 SUMMIT AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55105-3032
Practice Address - Country:US
Practice Address - Phone:651-227-6369
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN39361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical