Provider Demographics
NPI:1285037499
Name:NELLIGAN, KERRY (PSYD)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:
Last Name:NELLIGAN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 FENWOOD RD
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-6103
Mailing Address - Country:US
Mailing Address - Phone:617-626-9774
Mailing Address - Fax:617-626-9531
Practice Address - Street 1:75 FENWOOD RD
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-6103
Practice Address - Country:US
Practice Address - Phone:617-626-9774
Practice Address - Fax:617-626-9531
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-01
Last Update Date:2014-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA9921103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical