Healthcare Provider Details

I. General information

NPI: 1780166603
Provider Name (Legal Business Name): EVOANNA KILEEN KELLEY CORREA LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2018
Last Update Date: 08/12/2025
Certification Date: 08/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4619 9TH ST NW APT 2
ALBUQUERQUE NM
87107-3758
US

IV. Provider business mailing address

4619 9TH ST NW APT 2
ALBUQUERQUE NM
87107-3758
US

V. Phone/Fax

Practice location:
  • Phone: 608-449-3837
  • Fax:
Mailing address:
  • Phone: 608-449-3847
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number9639-123
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW24815
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSWB-2024-1306
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: