Healthcare Provider Details

I. General information

NPI: 1861474066
Provider Name (Legal Business Name): MARY MORRIS KELLEY MSW, LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/15/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

384 COUNTY ST THE GILBERT RUSSELL HOUSE, 2ND FL
NEW BEDFORD MA
02740-4980
US

IV. Provider business mailing address

33 CYPRESS ST
PORTSMOUTH RI
02871-1220
US

V. Phone/Fax

Practice location:
  • Phone: 508-996-5418
  • Fax: 508-996-5474
Mailing address:
  • Phone: 401-683-4331
  • Fax: 508-996-5474

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number110374
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: