Provider Demographics
NPI:1659659712
Name:KESSEL, IRENE (MT-BC)
Entity Type:Individual
Prefix:
First Name:IRENE
Middle Name:
Last Name:KESSEL
Suffix:
Gender:F
Credentials:MT-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 WAVERLY OAKS RD
Mailing Address - Street 2:BUILDING #3, SUITE 305
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02452-8448
Mailing Address - Country:US
Mailing Address - Phone:781-894-6564
Mailing Address - Fax:
Practice Address - Street 1:411 WAVERLY OAKS RD
Practice Address - Street 2:BUILDING #3, SUITE 305
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02452-8448
Practice Address - Country:US
Practice Address - Phone:781-894-6564
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-23
Last Update Date:2011-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA07531225A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAWKESS001-COtherMA DMR AUTISM WAIVER PROGRAM