Provider Demographics
NPI:1447388293
Name:KELLY, SHAUN MICHAEL (MA,LADC1 CAC)
Entity Type:Individual
Prefix:MR
First Name:SHAUN
Middle Name:MICHAEL
Last Name:KELLY
Suffix:
Gender:M
Credentials:MA,LADC1 CAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605-2401
Mailing Address - Country:US
Mailing Address - Phone:508-453-3056
Mailing Address - Fax:
Practice Address - Street 1:107 LINCOLN ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605-2401
Practice Address - Country:US
Practice Address - Phone:508-453-3056
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA33101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional