Provider Demographics
NPI:1346386703
Name:SMITH, KELLIE J (MS, ATC)
Entity Type:Individual
Prefix:MRS
First Name:KELLIE
Middle Name:J
Last Name:SMITH
Suffix:
Gender:F
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:185 MAIN ST.
Mailing Address - Street 2:UNIT F
Mailing Address - City:CONCORD
Mailing Address - State:MA
Mailing Address - Zip Code:01742
Mailing Address - Country:US
Mailing Address - Phone:978-402-2341
Mailing Address - Fax:
Practice Address - Street 1:166 MAIN ST
Practice Address - Street 2:CONCORD ACADEMY
Practice Address - City:CONCORD
Practice Address - State:MA
Practice Address - Zip Code:01742-2445
Practice Address - Country:US
Practice Address - Phone:978-402-2341
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA14422255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer