Provider Demographics
NPI:1811060924
Name:KELLEY, KELLY YOUNG (MSW)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:YOUNG
Last Name:KELLEY
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:MRS
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:YOUNG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:2915 E ESTRELLA CT
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85296-8897
Mailing Address - Country:US
Mailing Address - Phone:860-729-6288
Mailing Address - Fax:
Practice Address - Street 1:1300 N 12TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-2848
Practice Address - Country:US
Practice Address - Phone:602-839-3927
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2011-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0066841041C0700X
AZLMSW 132771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical