Provider Demographics
NPI:1922738996
Name:MILLS, KELLY (LICSW)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MILLS
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 1:521 MCDEVITT ST
Mailing Address - Street 2:
Mailing Address - City:SHAKOPEE
Mailing Address - State:MN
Mailing Address - Zip Code:55379-2248
Mailing Address - Country:US
Mailing Address - Phone:789-697-2948
Mailing Address - Fax:
Practice Address - Street 1:585 E RIVER ST
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:MA
Practice Address - Zip Code:01364-1811
Practice Address - Country:US
Practice Address - Phone:978-575-4175
Practice Address - Fax:978-849-5192
Is Sole Proprietor?:No
Enumeration Date:2022-06-13
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1264561041C0700X
1041C0700X
MN273611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical