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General NPI Number Information
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NPI Number | 1164573747
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Entity Type | Individual
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Provider Name | SANDRA EMILY COUCH KELLY LCSW
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Gender | Female
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Dates
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Enumeration Date | 01/12/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 410 BRIDGE ST CONGIN SCHOOL
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City | WESTBROOK
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State | ME
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Zip | 04092-3185
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Country | US
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Telephone | 207-854-0844
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Fax | 207-854-0846
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Provider Business Mailing Address
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Address Line | 13 NORTHLEDGE TER
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City | FALMOUTH
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State | ME
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Zip | 04105-2819
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Country | US
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Telephone | 207-874-7994
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | LC6148
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License Number State | ME
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