=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790236420
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELLY A CONN MSW, LSW,
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/18/2016
-----------------------------------------------------
Last Update Date | 08/27/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1490 E MAIN ST
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43205-2140
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-652-0679
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9079 PORTOFINO PL
-----------------------------------------------------
City | DUBLIN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43016-6274
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-652-0679
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | I.2203493-SUPV
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------