Provider Demographics
NPI:1063913721
Name:MASSIE, KELSEY JANE MORELL (LICSW, MSW)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:JANE MORELL
Last Name:MASSIE
Suffix:
Gender:F
Credentials:LICSW, MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 14
Mailing Address - Street 2:
Mailing Address - City:LONG LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55356-0014
Mailing Address - Country:US
Mailing Address - Phone:914-393-3578
Mailing Address - Fax:
Practice Address - Street 1:2355 MN-36
Practice Address - Street 2:#200
Practice Address - City:ST. PAUL
Practice Address - State:MN
Practice Address - Zip Code:55113
Practice Address - Country:US
Practice Address - Phone:914-393-3578
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-27
Last Update Date:2024-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 251B00000X
MN9407101041S0200X
MN271731041C0700X
NY0983721041C0700X
CO00099214661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No251B00000XAgenciesCase Management
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY098372OtherNEW YORK STATE DEPARTMENT OF EDUCATION
CO0009921466OtherDEPARTMENT OF REGULATORY AGENCIES
MN27173OtherMINNESOTA BOARD OF SOCIAL WORK