Provider Demographics
NPI:1699253732
Name:KELLY, RUBY P
Entity type:Individual
Prefix:
First Name:RUBY
Middle Name:P
Last Name:KELLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 W 71ST ST APT 1311
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60621-3665
Mailing Address - Country:US
Mailing Address - Phone:312-502-2441
Mailing Address - Fax:
Practice Address - Street 1:1525 E 53RD ST STE 904
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60615-4572
Practice Address - Country:US
Practice Address - Phone:312-203-2370
Practice Address - Fax:331-288-8613
Is Sole Proprietor?:No
Enumeration Date:2018-07-31
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0027561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical