Provider Demographics
NPI:1326240151
Name:CASEY, KELLY ANN (PHD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:CASEY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:CHILDREN AND THE LAW PROGRAM
Mailing Address - Street 2:388 COMMONWEALTH AVE., LOWER LEVEL
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215
Mailing Address - Country:US
Mailing Address - Phone:617-585-7440
Mailing Address - Fax:
Practice Address - Street 1:CHILDREN AND THE LAW PROGRAM
Practice Address - Street 2:388 COMMONWEALTH AVE., LOWER LEVEL
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215
Practice Address - Country:US
Practice Address - Phone:617-585-7440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-04
Last Update Date:2009-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA9012103TF0200X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical