Provider Demographics
NPI:1336244763
Name:RUSSELL, KELLY GRAVINO (LICSW)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:GRAVINO
Last Name:RUSSELL
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 1:16 BUSH HILL RD
Mailing Address - Street 2:
Mailing Address - City:IPSWICH
Mailing Address - State:MA
Mailing Address - Zip Code:01938-1642
Mailing Address - Country:US
Mailing Address - Phone:978-810-8397
Mailing Address - Fax:
Practice Address - Street 1:16 BUSH HILL RD
Practice Address - Street 2:
Practice Address - City:IPSWICH
Practice Address - State:MA
Practice Address - Zip Code:01938-1642
Practice Address - Country:US
Practice Address - Phone:978-810-8397
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2020-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1103401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical