Provider Demographics
NPI:1902342991
Name:KELLEY, KAREN LOUISE
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:LOUISE
Last Name:KELLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11082 KNIGHTS RD
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19154-3511
Mailing Address - Country:US
Mailing Address - Phone:215-632-9040
Mailing Address - Fax:215-632-0610
Practice Address - Street 1:11082 KNIGHTS RD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19154-3511
Practice Address - Country:US
Practice Address - Phone:215-632-9040
Practice Address - Fax:215-632-0610
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-13
Last Update Date:2017-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0187301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical