Provider Demographics
NPI:1598801920
Name:KELLY, JOELLE ANN (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOELLE
Middle Name:ANN
Last Name:KELLY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 BAY STATE COURT
Mailing Address - Street 2:
Mailing Address - City:BREWSTER
Mailing Address - State:MA
Mailing Address - Zip Code:02631-2120
Mailing Address - Country:US
Mailing Address - Phone:508-430-0589
Mailing Address - Fax:508-430-5207
Practice Address - Street 1:23 BAY STATE COURT
Practice Address - Street 2:
Practice Address - City:BREWSTER
Practice Address - State:MA
Practice Address - Zip Code:02631-2120
Practice Address - Country:US
Practice Address - Phone:508-430-0589
Practice Address - Fax:508-430-5207
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPSY4274103TC0700X
MEPS0595103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0517879Medicaid
103041OtherVALUE OPTIONS INC HMO NEW
13445513OtherMAGELLAN BEHAVIORAL HEALT
0007491474OtherAETNA
005530OtherPACIFICARE OLD HPHC VALUE
MAW04483OtherBCBS MA
MAKEW04483OtherBCBS INDEMNITY
460402OtherTUFTS HEALTH CARE
W04483Medicare UPIN
0007491474OtherAETNA