Healthcare Provider Details

I. General information

NPI: 1932501566
Provider Name (Legal Business Name): CAROL J. KELLY LISW-S
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2014
Last Update Date: 03/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

68 W CHURCH ST STE 318
NEWARK OH
43055-5050
US

IV. Provider business mailing address

68 W CHURCH ST STE 318
NEWARK OH
43055-5050
US

V. Phone/Fax

Practice location:
  • Phone: 740-281-1777
  • Fax: 740-281-1778
Mailing address:
  • Phone: 740-281-1777
  • Fax: 740-281-1778

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI9919
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: