Provider Demographics
NPI:1154998250
Name:KELLEY, KATE (LICSW)
Entity type:Individual
Prefix:
First Name:KATE
Middle Name:
Last Name:KELLEY
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:69 BELLEVUE AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:WINTHROP
Mailing Address - State:MA
Mailing Address - Zip Code:02152-2202
Mailing Address - Country:US
Mailing Address - Phone:617-835-9109
Mailing Address - Fax:
Practice Address - Street 1:57 PUTNAM ST
Practice Address - Street 2:
Practice Address - City:WINTHROP
Practice Address - State:MA
Practice Address - Zip Code:02152-2902
Practice Address - Country:US
Practice Address - Phone:617-971-8335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-07
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA224529101YS0200X
MA1246041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchoolGroup - Multi-Specialty