Provider Demographics
NPI:1811328735
Name:KELLY, MICHELE (LISW)
Entity type:Individual
Prefix:
First Name:MICHELE
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:791 HAVENWOOD DR
Mailing Address - Street 2:
Mailing Address - City:NEW FRANKLIN
Mailing Address - State:OH
Mailing Address - Zip Code:44319-4238
Mailing Address - Country:US
Mailing Address - Phone:330-475-5095
Mailing Address - Fax:
Practice Address - Street 1:791 HAVENWOOD DR
Practice Address - Street 2:
Practice Address - City:NEW FRANKLIN
Practice Address - State:OH
Practice Address - Zip Code:44319-4238
Practice Address - Country:US
Practice Address - Phone:330-475-5095
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-02
Last Update Date:2013-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI 09000821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical