Healthcare Provider Details

I. General information

NPI: 1063913721
Provider Name (Legal Business Name): KELSEY JANE MORELL MASSIE LICSW, MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2018
Last Update Date: 12/20/2024
Certification Date: 12/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2355 MN-36 #200
ST. PAUL MN
55113
US

IV. Provider business mailing address

PO BOX 14
LONG LAKE MN
55356-0014
US

V. Phone/Fax

Practice location:
  • Phone: 914-393-3578
  • Fax:
Mailing address:
  • Phone: 914-393-3578
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number940710
License Number StateMN
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number27173
License Number StateMN
# 5
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number098372
License Number StateNY
# 6
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0009921466
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: