Provider Demographics
NPI:1639846132
Name:MCANELLY, KELLY LURA MAYLIN (LCSW)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:LURA MAYLIN
Last Name:MCANELLY
Suffix:
Gender:
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1450 AIRPORT BLVD STE 110
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-9030
Mailing Address - Country:US
Mailing Address - Phone:707-687-6575
Mailing Address - Fax:
Practice Address - Street 1:1450 AIRPORT BLVD STE 110
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-9030
Practice Address - Country:US
Practice Address - Phone:707-687-6575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-24
Last Update Date:2025-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
CA1208451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical