MEDICARE: KATHLEEN KAREN KELLY MA, MSW, LICSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	LC50078837	DC

General Provider Information

NPI Number	:	1083925853
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHLEEN KAREN KELLY MA, MSW, LICSW

Provider Business Mailing Address
First Line	:	5415 CONNECTICUT AVE NW
Second Line	:	SUITE T-43
City	:	WASHINGTON
State	:	DC
Zip	:	20015-2765
Country	:	US
Telephone Number	:	202-230-9307
Fax Number	:

Provider Business Practice Location Address
First Line	:	5415 CONNECTICUT AVE NW
Second Line	:	SUITE T-43
City	:	WASHINGTON
State	:	DC
Zip	:	20015-2765
Country	:	US
Telephone Number	:	202-230-9307
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/28/2010
Last Update Date	:	11/17/2012

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