Provider Demographics
NPI:1083768790
Name:KELTY, VIRGINIA A (PH D)
Entity Type:Individual
Prefix:DR
First Name:VIRGINIA
Middle Name:A
Last Name:KELTY
Suffix:
Gender:F
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 WASHINGTON PL
Mailing Address - Street 2:SUITE 104
Mailing Address - City:BRAINTREE
Mailing Address - State:MA
Mailing Address - Zip Code:02184-3259
Mailing Address - Country:US
Mailing Address - Phone:781-848-1903
Mailing Address - Fax:781-545-5189
Practice Address - Street 1:8 WASHINGTON PL
Practice Address - Street 2:SUITE 104
Practice Address - City:BRAINTREE
Practice Address - State:MA
Practice Address - Zip Code:02184-3259
Practice Address - Country:US
Practice Address - Phone:781-848-1903
Practice Address - Fax:781-545-5189
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4185103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW04122Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER