Healthcare Provider Details

I. General information

NPI: 1184271785
Provider Name (Legal Business Name): EILEEN KELLY LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2019
Last Update Date: 04/02/2025
Certification Date: 04/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1509 MAPLE ST
SCRANTON PA
18505-2707
US

IV. Provider business mailing address

336 BUTTERNUT FLTS
HONESDALE PA
18431-3062
US

V. Phone/Fax

Practice location:
  • Phone: 570-342-8305
  • Fax:
Mailing address:
  • Phone: 570-647-7725
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberSW136231
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCW023331
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier100759410-0048
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer
# 2
Identifier100759410-0018
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: