MEDICARE: MR. KEVIN PATRICK KELLY MSW

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	13200	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	62-76668	OTHER	MN	UNITED BEHAVIORAL HEALTH
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	91G35KE	OTHER	MN	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1730123795
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KEVIN PATRICK KELLY MSW

Provider Business Mailing Address
First Line	:	241 CLEVELAND AVE S
Second Line	:	SUITE B3
City	:	SAINT PAUL
State	:	MN
Zip	:	55105-1208
Country	:	US
Telephone Number	:	651-698-2773
Fax Number	:	651-698-2776

Provider Business Practice Location Address
First Line	:	241 CLEVELAND AVE S
Second Line	:	SUITE B3
City	:	SAINT PAUL
State	:	MN
Zip	:	55105-1208
Country	:	US
Telephone Number	:	651-698-2773
Fax Number	:	651-698-2776

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

Provider Enumeration Date	:	06/16/2006
Last Update Date	:	06/07/2009

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