Provider Demographics
NPI:1366770281
Name:KELLY, MARY CATHERINE (LMHC, RN)
Entity type:Individual
Prefix:MS
First Name:MARY CATHERINE
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:LMHC, RN
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:CATHERINE
Other - Last Name:WHARTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMHC
Mailing Address - Street 1:33 COLLEGE HILL RD STE 29C
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02886-2775
Mailing Address - Country:US
Mailing Address - Phone:401-822-4673
Mailing Address - Fax:401-822-4676
Practice Address - Street 1:33 COLLEGE HILL RD STE 29C
Practice Address - Street 2:
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02886
Practice Address - Country:US
Practice Address - Phone:401-822-4673
Practice Address - Fax:401-822-4676
Is Sole Proprietor?:No
Enumeration Date:2009-12-04
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMHC00450101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIMHC00450OtherSTATE LICENSE