Healthcare Provider Details

I. General information

NPI: 1992999296
Provider Name (Legal Business Name): RUTH LYNNE KELLY LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2007
Last Update Date: 08/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

I40 W EXIT 131 HIGHWAY 56 N ACL TEEN CENTERS TO'HAJIILEE COMMUNITY SCHOOL
TO'HAJIILEE NM
87026
US

IV. Provider business mailing address

2703 FRONTIER STE 120 UNM PRC ACL TEEN CENTERS MSC 11 6145
ALBUQUERQUE NM
87131-0001
US

V. Phone/Fax

Practice location:
  • Phone: 505-908-2377
  • Fax: 505-908-2370
Mailing address:
  • Phone: 505-272-4462
  • Fax: 505-272-4857

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberM-06496
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: