Provider Demographics
NPI:1366408098
Name:KELLEY, CATHLEEN M (LICSW)
Entity type:Individual
Prefix:
First Name:CATHLEEN
Middle Name:M
Last Name:KELLEY
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 1:46 MCMULLEN LN
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:VT
Mailing Address - Zip Code:05405-1764
Mailing Address - Country:US
Mailing Address - Phone:802-878-3077
Mailing Address - Fax:802-656-3485
Practice Address - Street 1:2 COLCHESTER AVE
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05405-1764
Practice Address - Country:US
Practice Address - Phone:802-656-2661
Practice Address - Fax:802-656-3485
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2017-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT08900002771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT28173OtherBLUE CROSS BLUE SHIELD
VT1007281Medicaid
2302377OtherCIGNA BEHAVIORAL HEALTH
094775OtherVALUE OPTIONS
VTVN2413Medicare ID - Type Unspecified