Provider Demographics
NPI:1275849259
Name:DESJARDINS, KELLY ANNE (BA)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:ANNE
Last Name:DESJARDINS
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:293 WENTWORTH AVE
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:MA
Mailing Address - Zip Code:01852-3818
Mailing Address - Country:US
Mailing Address - Phone:978-807-8424
Mailing Address - Fax:
Practice Address - Street 1:126 PHOENIX AVE
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01852-4931
Practice Address - Country:US
Practice Address - Phone:978-513-2399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-27
Last Update Date:2010-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker