Provider Demographics
NPI:1184113599
Name:REDMOND, KELLY (MA)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:REDMOND
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 PINE TREE DR
Mailing Address - Street 2:
Mailing Address - City:CRESCO
Mailing Address - State:PA
Mailing Address - Zip Code:18326-7334
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2208 QUARRY DR STE 200
Practice Address - Street 2:
Practice Address - City:READING
Practice Address - State:PA
Practice Address - Zip Code:19609-1158
Practice Address - Country:US
Practice Address - Phone:610-563-2052
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-02
Last Update Date:2018-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW1335901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SW133590OtherLICENSE