Provider Demographics
NPI:1306129960
Name:KELLY, ALEXIS CATHERINE (MSW, LCSW)
Entity type:Individual
Prefix:
First Name:ALEXIS
Middle Name:CATHERINE
Last Name:KELLY
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:ALEXIS
Other - Middle Name:CATHERINE
Other - Last Name:AMES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:171 KRAKY RD
Mailing Address - Street 2:
Mailing Address - City:SCOTT TOWNSHIP
Mailing Address - State:PA
Mailing Address - Zip Code:18447-7657
Mailing Address - Country:US
Mailing Address - Phone:570-407-3869
Mailing Address - Fax:
Practice Address - Street 1:1509 N MAIN AVE
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18508-1866
Practice Address - Country:US
Practice Address - Phone:570-407-3869
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-21
Last Update Date:2017-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0189691041C0700X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008003511Medicaid