Provider Demographics
NPI:1912055054
Name:KELLETT, MARY JEAN (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:JEAN
Last Name:KELLETT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:9812 SHELBYVILLE RD
Mailing Address - Street 2:SUITE 4
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-2906
Mailing Address - Country:US
Mailing Address - Phone:502-423-0509
Mailing Address - Fax:502-423-1599
Practice Address - Street 1:9812 SHELBYVILLE RD
Practice Address - Street 2:SUITE 4
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40223-2906
Practice Address - Country:US
Practice Address - Phone:502-423-0509
Practice Address - Fax:502-423-1599
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY9541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical