Provider Demographics
NPI:1578814034
Name:VIERA, KELLY MCGOWAN (MA, LSAC)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:MCGOWAN
Last Name:VIERA
Suffix:
Gender:F
Credentials:MA, LSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 BRADFORD RD
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01757-3812
Mailing Address - Country:US
Mailing Address - Phone:508-579-6346
Mailing Address - Fax:
Practice Address - Street 1:83 BLACKSTONE ST
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:MA
Practice Address - Zip Code:02019-1637
Practice Address - Country:US
Practice Address - Phone:508-579-6346
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-25
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA50835252101YS0200X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA50835252OtherDESE