Provider Demographics
NPI:1295335511
Name:KELLY, KATHLEEN (MSW, LCSW)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1672 S OCEAN LN APT 155
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33316-3341
Mailing Address - Country:US
Mailing Address - Phone:860-463-4723
Mailing Address - Fax:
Practice Address - Street 1:1672 S OCEAN LN APT 155
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33316-3341
Practice Address - Country:US
Practice Address - Phone:860-463-4723
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0015911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical