Provider Demographics
NPI:1093844193
Name:KELLEY, SUSAN R (MED)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:R
Last Name:KELLEY
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:FALMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02540-2659
Mailing Address - Country:US
Mailing Address - Phone:508-540-3363
Mailing Address - Fax:
Practice Address - Street 1:200 TER HEUN DR
Practice Address - Street 2:
Practice Address - City:FALMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02540-2525
Practice Address - Country:US
Practice Address - Phone:508-540-6550
Practice Address - Fax:508-540-7480
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPENDING101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health