Provider Demographics
NPI:1740337898
Name:KELLEY, JUDITH M (MSW, LICSW, LADC1)
Entity type:Individual
Prefix:MS
First Name:JUDITH
Middle Name:M
Last Name:KELLEY
Suffix:
Gender:F
Credentials:MSW, LICSW, LADC1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 302
Mailing Address - Street 2:
Mailing Address - City:FALMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02541-0302
Mailing Address - Country:US
Mailing Address - Phone:508-457-4955
Mailing Address - Fax:508-457-4955
Practice Address - Street 1:15 DAVEDON DR
Practice Address - Street 2:
Practice Address - City:EAST FALMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02536-5046
Practice Address - Country:US
Practice Address - Phone:508-457-4955
Practice Address - Fax:508-457-4955
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1110031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA111003OtherLICSW
MA1106OtherLADC 1