Healthcare Provider Details

I. General information

NPI: 1821351057
Provider Name (Legal Business Name): KERRI KELLEY LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2012
Last Update Date: 06/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

146 W RIVER ST SUITE 11-A
PROVIDENCE RI
02904-2609
US

IV. Provider business mailing address

146 W RIVER ST SUITE 11-A
PROVIDENCE RI
02904-2609
US

V. Phone/Fax

Practice location:
  • Phone: 401-793-8770
  • Fax: 401-793-8709
Mailing address:
  • Phone: 401-793-8770
  • Fax: 401-793-8709

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberISW02204
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: