Provider Demographics
NPI:1366905861
Name:KELLY MARIE LLC
Entity type:Organization
Organization Name:KELLY MARIE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:BARRETT
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:203-260-9677
Mailing Address - Street 1:1011 HOPE ST STE R
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06907-2121
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1011 HOPE ST STE R
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06907-2121
Practice Address - Country:US
Practice Address - Phone:203-260-9677
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-11
Last Update Date:2019-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty