Provider Demographics
NPI:1518190222
Name:MAYNES, KELLY ANN (PSYD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:MAYNES
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:280 CHESTNUT ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01199-1001
Mailing Address - Country:US
Mailing Address - Phone:413-794-5700
Mailing Address - Fax:
Practice Address - Street 1:3300 MAIN ST
Practice Address - Street 2:4TH FLOOR, STE A
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01107-1112
Practice Address - Country:US
Practice Address - Phone:413-794-7284
Practice Address - Fax:413-794-7140
Is Sole Proprietor?:No
Enumeration Date:2009-08-27
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10323103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR210855Medicaid