1801002555 NPI number — MRS. KELLY KEVILLE CANNEY P.T.

Table of content: MRS. KELLY KEVILLE CANNEY P.T. (NPI 1801002555)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801002555 NPI number — MRS. KELLY KEVILLE CANNEY P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CANNEY
Provider First Name:
KELLY
Provider Middle Name:
KEVILLE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
P.T.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KEVILLE
Provider Other First Name:
KELLY
Provider Other Middle Name:
ELIZABETH
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
P.T.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1801002555
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/06/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8 CHERRY ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MILLBURY
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01527-2612
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
774-270-0813
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3 BURLINGTON WOODS
Provider Second Line Business Practice Location Address:
SUITE 304
Provider Business Practice Location Address City Name:
BURLINGTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01803-4514
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
781-270-0222
Provider Business Practice Location Address Fax Number:
781-270-5005
Provider Enumeration Date:
05/16/2007

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: 225100000X , with the licence number:  15322 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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