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General NPI Number Information
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NPI Number | 1841469111
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Entity Type | Individual
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Provider Name | MARY KELLY L.S.W.
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Gender | Female
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Dates
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Enumeration Date | 02/21/2008
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Last Update Date | 02/21/2008
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Provider Practice Location Address
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Address Line | 6140 S BROADWAY
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City | LORAIN
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State | OH
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Zip | 44053-3821
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Country | US
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Telephone | 440-204-4100
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Fax | 440-233-9070
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Provider Business Mailing Address
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Address Line | 696 ASHBERRY LN
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City | AVON LAKE
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State | OH
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Zip | 44012-5207
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Country | US
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Telephone | 440-930-2944
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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 | 104100000X
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Taxonomy Name | Social Worker
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License Number | S-0028760
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License Number State | OH
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