Provider Demographics
NPI:1568010205
Name:KELLY, SAMANTHA ELIZABETH (LBSW)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:ELIZABETH
Last Name:KELLY
Suffix:
Gender:F
Credentials:LBSW
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:ELIZABETH
Other - Last Name:KOCHANOWSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LBSW
Mailing Address - Street 1:1010 DOWNING AVE STE 60
Mailing Address - Street 2:
Mailing Address - City:HAYS
Mailing Address - State:KS
Mailing Address - Zip Code:67601-2461
Mailing Address - Country:US
Mailing Address - Phone:785-621-4417
Mailing Address - Fax:866-473-6903
Practice Address - Street 1:1010 DOWNING AVE STE 60
Practice Address - Street 2:
Practice Address - City:HAYS
Practice Address - State:KS
Practice Address - Zip Code:67601-2461
Practice Address - Country:US
Practice Address - Phone:785-621-4417
Practice Address - Fax:866-473-6903
Is Sole Proprietor?:No
Enumeration Date:2019-08-27
Last Update Date:2019-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS8386104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker