Provider Demographics
NPI:1093709164
Name:MADDALENA, KELLY A (LCSW, LMHP, LIMHP)
Entity type:Individual
Prefix:MS
First Name:KELLY
Middle Name:A
Last Name:MADDALENA
Suffix:
Gender:F
Credentials:LCSW, LMHP, LIMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15106 SPENCER ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68116-8106
Mailing Address - Country:US
Mailing Address - Phone:402-594-4911
Mailing Address - Fax:
Practice Address - Street 1:15106 SPENCER ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68116-8106
Practice Address - Country:US
Practice Address - Phone:402-594-4911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-06
Last Update Date:2024-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE509101YM0800X
NE1006104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
85120OtherBCBS
P40029Medicare UPIN
85120OtherBCBS