Provider Demographics
NPI:1841469111
Name:KELLY, MARY (LSW)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:KELLY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LSW
Mailing Address - Street 1:696 ASHBERRY LN
Mailing Address - Street 2:
Mailing Address - City:AVON LAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44012-5207
Mailing Address - Country:US
Mailing Address - Phone:440-930-2944
Mailing Address - Fax:
Practice Address - Street 1:6140 S BROADWAY
Practice Address - Street 2:
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44053-3821
Practice Address - Country:US
Practice Address - Phone:440-204-4100
Practice Address - Fax:440-233-9070
Is Sole Proprietor?:No
Enumeration Date:2008-02-21
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS-0028760104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker