Provider Demographics
NPI:1811926801
Name:BARNES, KELLY L (LICSW)
Entity type:Individual
Prefix:MS
First Name:KELLY
Middle Name:L
Last Name:BARNES
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:L
Other - Last Name:WICKERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LICSW
Mailing Address - Street 1:43 VILLAGE VIEW RD
Mailing Address - Street 2:
Mailing Address - City:WESTFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01886-2359
Mailing Address - Country:US
Mailing Address - Phone:808-349-0068
Mailing Address - Fax:
Practice Address - Street 1:43 VILLAGE VIEW RD
Practice Address - Street 2:
Practice Address - City:WESTFORD
Practice Address - State:MA
Practice Address - Zip Code:01886-2359
Practice Address - Country:US
Practice Address - Phone:808-349-0068
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-02
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HILCSW-33321041C0700X
MA1118081041C0700X
MA1213971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI814562OtherUNIVERSITY HEALTH ALLIANC
HI578792Medicaid
HI101416Medicare ID - Type Unspecified
HI578792Medicaid