Provider Demographics
NPI:1497084081
Name:KELLY, TERESA MARY
Entity Type:Individual
Prefix:MS
First Name:TERESA
Middle Name:MARY
Last Name:KELLY
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:TERESA
Other - Middle Name:M
Other - Last Name:KELLY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSW
Mailing Address - Street 1:30 STARK ST
Mailing Address - Street 2:
Mailing Address - City:NASHUA
Mailing Address - State:NH
Mailing Address - Zip Code:03064-6223
Mailing Address - Country:US
Mailing Address - Phone:774-258-0800
Mailing Address - Fax:
Practice Address - Street 1:24 LYMAN ST
Practice Address - Street 2:
Practice Address - City:WESTBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01581-1482
Practice Address - Country:US
Practice Address - Phone:508-475-9110
Practice Address - Fax:508-422-9730
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-10
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2159991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical