Provider Demographics
NPI:1699928416
Name:KELLY-ZAZADO, KELLY CATHLEEN (LCSW/ACSW)
Entity type:Individual
Prefix:MS
First Name:KELLY
Middle Name:CATHLEEN
Last Name:KELLY-ZAZADO
Suffix:
Gender:F
Credentials:LCSW/ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 W. 10TH ST., LAKE ERIE COUNSELING, INC
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16502
Mailing Address - Country:US
Mailing Address - Phone:814-455-4009
Mailing Address - Fax:814-455-7715
Practice Address - Street 1:301 W. 10TH ST., LAKE ERIE COUNSELING, INC
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16502
Practice Address - Country:US
Practice Address - Phone:814-455-4009
Practice Address - Fax:814-455-7715
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-23
Last Update Date:2019-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0069631041C0700X
PACW0167021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102774194Medicaid