Healthcare Provider Details

I. General information

NPI: 1285223677
Provider Name (Legal Business Name): KELLY ESPY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/11/2021
Last Update Date: 01/11/2021
Certification Date: 01/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

512 SHAW ST
ROCKFORD IL
61104-1536
US

IV. Provider business mailing address

512 SHAW ST
ROCKFORD IL
61104-1536
US

V. Phone/Fax

Practice location:
  • Phone: 815-997-7125
  • Fax:
Mailing address:
  • Phone: 815-997-7125
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.022816
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: