Provider Demographics
NPI:1346030681
Name:KELLY, SIOBHAN (LICSW)
Entity type:Individual
Prefix:
First Name:SIOBHAN
Middle Name:
Last Name:KELLY
Suffix:
Gender:
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 CHESTNUT ST APT 5
Mailing Address - Street 2:
Mailing Address - City:WAKEFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01880-2325
Mailing Address - Country:US
Mailing Address - Phone:781-572-2513
Mailing Address - Fax:
Practice Address - Street 1:12 CHESTNUT ST APT 5
Practice Address - Street 2:
Practice Address - City:WAKEFIELD
Practice Address - State:MA
Practice Address - Zip Code:01880-2325
Practice Address - Country:US
Practice Address - Phone:781-572-2513
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-09
Last Update Date:2025-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2278211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical