MEDICARE: KELLEY JEAN GROVER LCSW

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	LC11550	ME

General Provider Information

NPI Number	:	1669531828
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLEY JEAN GROVER LCSW

Provider Business Mailing Address
First Line	:	223 S LIVERMORE RD
Second Line	:
City	:	TURNER
State	:	ME
Zip	:	04282-3102
Country	:	US
Telephone Number	:	207-577-1646
Fax Number	:

Provider Business Practice Location Address
First Line	:	540 OLD COUNTY RD
Second Line	:
City	:	ETNA
State	:	ME
Zip	:	04434-3818
Country	:	US
Telephone Number	:	207-577-1646
Fax Number	:

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

Provider Enumeration Date	:	12/06/2006
Last Update Date	:	01/09/2020

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