Provider Demographics
NPI:1093457905
Name:KELLY MITCHELL, PSYD LLC
Entity Type:Organization
Organization Name:KELLY MITCHELL, PSYD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:508-380-8757
Mailing Address - Street 1:592A WASHINGTON ST FL 2
Mailing Address - Street 2:
Mailing Address - City:WELLESLEY
Mailing Address - State:MA
Mailing Address - Zip Code:02482-6417
Mailing Address - Country:US
Mailing Address - Phone:508-380-8757
Mailing Address - Fax:
Practice Address - Street 1:592A WASHINGTON ST FL 2
Practice Address - Street 2:
Practice Address - City:WELLESLEY
Practice Address - State:MA
Practice Address - Zip Code:02482-6417
Practice Address - Country:US
Practice Address - Phone:508-380-8757
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-11
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NONEOtherNONE