Provider Demographics
NPI:1376802272
Name:BENWAY, KELLEEN JANE III (BA PSYCHOLOGY)
Entity Type:Individual
Prefix:MRS
First Name:KELLEEN
Middle Name:JANE
Last Name:BENWAY
Suffix:III
Gender:F
Credentials:BA PSYCHOLOGY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01540-2344
Mailing Address - Country:US
Mailing Address - Phone:508-987-2518
Mailing Address - Fax:
Practice Address - Street 1:340 MAIN STREET
Practice Address - Street 2:SOUTH BAY DAY SERVICES
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01608
Practice Address - Country:US
Practice Address - Phone:508-752-3969
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-11
Last Update Date:2012-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health