Basic Information
| Provider Information | |||||||||
| NPI: | 1811926801 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BARNES | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LICSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WICKERS | ||||||||
| OtherFirstName: | KELLY | ||||||||
| OtherMiddleName: | L. | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LICSW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 43 VILLAGE VIEW RD | ||||||||
| Address2: | |||||||||
| City: | WESTFORD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018862359 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8083490068 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 43 VILLAGE VIEW RD | ||||||||
| Address2: | |||||||||
| City: | WESTFORD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018862359 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8083490068 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2006 | ||||||||
| LastUpdateDate: | 04/16/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | LCSW-3332 | HI | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 111808 | MA | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 121397 | MA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 814562 | 01 | HI | UNIVERSITY HEALTH ALLIANC | OTHER | 578792 | 05 | HI | MEDICAID |