Provider Demographics
NPI:1457136525
Name:MARA, KELLY COURTLAND (LMSW)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:COURTLAND
Last Name:MARA
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3426 CRESCENT ST
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11106-3918
Mailing Address - Country:US
Mailing Address - Phone:508-221-8837
Mailing Address - Fax:
Practice Address - Street 1:3426 CRESCENT ST
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11106-3918
Practice Address - Country:US
Practice Address - Phone:508-221-8837
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-28
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY109417104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker