Provider Demographics
NPI:1235275280
Name:KELSEY, PETER V (LICSW)
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:V
Last Name:KELSEY
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 CRESCENT ST
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02138-1907
Mailing Address - Country:US
Mailing Address - Phone:617-547-7537
Mailing Address - Fax:617-547-7537
Practice Address - Street 1:328 BROADWAY
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02139-1840
Practice Address - Country:US
Practice Address - Phone:617-547-7537
Practice Address - Fax:617-547-7537
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10195021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP05617OtherBCBS PPO
MAPP0210OtherBCBS INDEMNITY
MAKE PP0210Medicare ID - Type Unspecified