1598801920 NPI number — DR. JOELLE ANN KELLY PHD

Table of content: DR. JOELLE ANN KELLY PHD (NPI 1598801920)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598801920 NPI number — DR. JOELLE ANN KELLY PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KELLY
Provider First Name:
JOELLE
Provider Middle Name:
ANN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1598801920
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
23 BAY STATE COURT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BREWSTER
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02631-2120
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-430-0589
Provider Business Mailing Address Fax Number:
508-430-5207

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
23 BAY STATE COURT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BREWSTER
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02631-2120
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-430-0589
Provider Business Practice Location Address Fax Number:
508-430-5207
Provider Enumeration Date:
01/30/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  PSY4274 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 103TC0700X , with the licence number: PS0595 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0517879 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 103041 . This is a "VALUE OPTIONS INC HMO NEW" identifier . This identifiers is of the category "OTHER".
  • Identifier: 13445513 . This is a "MAGELLAN BEHAVIORAL HEALT" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0007491474 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 005530 . This is a "PACIFICARE OLD HPHC VALUE" identifier . This identifiers is of the category "OTHER".
  • Identifier: W04483 . This is a "BCBS MA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: KEW04483 . This is a "BCBS INDEMNITY" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 460402 . This is a "TUFTS HEALTH CARE" identifier . This identifiers is of the category "OTHER".




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