Provider Demographics
NPI:1205288842
Name:KELLY, CYNTHIA (LICSW)
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:497 MALL RD
Mailing Address - Street 2:
Mailing Address - City:OAK HILL
Mailing Address - State:WV
Mailing Address - Zip Code:25901-6216
Mailing Address - Country:US
Mailing Address - Phone:304-469-2905
Mailing Address - Fax:304-465-1518
Practice Address - Street 1:497 MALL RD
Practice Address - Street 2:
Practice Address - City:OAK HILL
Practice Address - State:WV
Practice Address - Zip Code:25901-6216
Practice Address - Country:US
Practice Address - Phone:304-469-2905
Practice Address - Fax:304-465-1518
Is Sole Proprietor?:No
Enumeration Date:2016-07-07
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVDP009392181041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1205288842Medicaid