Provider Demographics
NPI:1992913529
Name:KELLEY, MARY L (LCPC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:L
Last Name:KELLEY
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1090 POST RD
Mailing Address - Street 2:
Mailing Address - City:BOWDOINHAM
Mailing Address - State:ME
Mailing Address - Zip Code:04008
Mailing Address - Country:US
Mailing Address - Phone:207-737-9001
Mailing Address - Fax:
Practice Address - Street 1:682 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:BATH
Practice Address - State:ME
Practice Address - Zip Code:04530
Practice Address - Country:US
Practice Address - Phone:207-442-0682
Practice Address - Fax:707-442-0680
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECC2124101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
098941OtherANTHEM