Provider Demographics
NPI:1821568676
Name:KELLEY, CAROL (LCSW)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:KELLEY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:317 JANERO PL
Mailing Address - Street 2:
Mailing Address - City:SONOMA
Mailing Address - State:CA
Mailing Address - Zip Code:95476-7353
Mailing Address - Country:US
Mailing Address - Phone:707-529-9524
Mailing Address - Fax:
Practice Address - Street 1:21 PATTEN ST
Practice Address - Street 2:
Practice Address - City:SONOMA
Practice Address - State:CA
Practice Address - Zip Code:95476-6726
Practice Address - Country:US
Practice Address - Phone:707-529-9524
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-04
Last Update Date:2018-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical