Provider Demographics
NPI:1083169361
Name:GAGLIARDO, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:GAGLIARDO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 BOULDER DR APT 14H
Mailing Address - Street 2:
Mailing Address - City:ORONO
Mailing Address - State:ME
Mailing Address - Zip Code:04473-4681
Mailing Address - Country:US
Mailing Address - Phone:207-341-4043
Mailing Address - Fax:
Practice Address - Street 1:41 BOULDER DR APT 14H
Practice Address - Street 2:
Practice Address - City:ORONO
Practice Address - State:ME
Practice Address - Zip Code:04473-4681
Practice Address - Country:US
Practice Address - Phone:207-341-4043
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-16
Last Update Date:2016-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical