Provider Demographics
NPI:1700093317
Name:KELLY, JUDITH CLAIRE (LCSW, CSAT)
Entity Type:Individual
Prefix:MRS
First Name:JUDITH
Middle Name:CLAIRE
Last Name:KELLY
Suffix:
Gender:F
Credentials:LCSW, CSAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4082 MUIRWOOD LN
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95747-9796
Mailing Address - Country:US
Mailing Address - Phone:916-771-0405
Mailing Address - Fax:916-771-5263
Practice Address - Street 1:411 OAK ST
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95678-2618
Practice Address - Country:US
Practice Address - Phone:916-783-3420
Practice Address - Fax:916-771-5263
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS152221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical