Provider Demographics
NPI:1578090643
Name:SOUSA, KELLY (MED, BCBA, LABA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:SOUSA
Suffix:
Gender:F
Credentials:MED, BCBA, LABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 ABORN ST # 3
Mailing Address - Street 2:
Mailing Address - City:PEABODY
Mailing Address - State:MA
Mailing Address - Zip Code:01960-5657
Mailing Address - Country:US
Mailing Address - Phone:781-726-0261
Mailing Address - Fax:
Practice Address - Street 1:75 ABORN ST # 3
Practice Address - Street 2:
Practice Address - City:PEABODY
Practice Address - State:MA
Practice Address - Zip Code:01960-5657
Practice Address - Country:US
Practice Address - Phone:781-726-0261
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1016103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst