Provider Demographics
NPI:1437103207
Name:KELLY, TARA (LMHC)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:
Other - Last Name:BISCEGLIA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:122 TAYLOR AVE
Mailing Address - Street 2:
Mailing Address - City:DEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02026
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:95 WEST STREET
Practice Address - Street 2:
Practice Address - City:WALPOLE
Practice Address - State:MA
Practice Address - Zip Code:02081
Practice Address - Country:US
Practice Address - Phone:508-660-1570
Practice Address - Fax:500-660-3122
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5541104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
5541OtherLICENSE