Provider Demographics
NPI:1497131239
Name:KELLY, ALICE Z (LCSW)
Entity type:Individual
Prefix:
First Name:ALICE
Middle Name:Z
Last Name:KELLY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 SKY TOP DRIVE
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06825
Mailing Address - Country:US
Mailing Address - Phone:203-374-3483
Mailing Address - Fax:203-371-0249
Practice Address - Street 1:113 SKY TOP DRIVE
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06825
Practice Address - Country:US
Practice Address - Phone:203-374-3483
Practice Address - Fax:203-371-0249
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-04
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0023731041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT800000470Medicare UPIN