Healthcare Provider Details

I. General information

NPI: 1023507837
Provider Name (Legal Business Name): HUGH MICHAEL KELLY LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2018
Last Update Date: 05/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 TROY RD
DETROIT ME
04929-3015
US

IV. Provider business mailing address

PO BOX 35
DETROIT ME
04929-0035
US

V. Phone/Fax

Practice location:
  • Phone: 207-217-0340
  • Fax:
Mailing address:
  • Phone: 207-217-0340
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC15379
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: