Provider Demographics
NPI:1093340853
Name:DIONNE, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:DIONNE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:HAVENAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:66 STARKWEATHER HILL RD
Mailing Address - Street 2:
Mailing Address - City:WORTHINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:01098-9607
Mailing Address - Country:US
Mailing Address - Phone:937-214-7667
Mailing Address - Fax:
Practice Address - Street 1:1360 TORRINGFORD ST
Practice Address - Street 2:
Practice Address - City:TORRINGTON
Practice Address - State:CT
Practice Address - Zip Code:06790-3140
Practice Address - Country:US
Practice Address - Phone:860-489-1008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-11
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4557224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant