Provider Demographics
NPI:1740645878
Name:VANDER MASS, KELLY (MS OTR/L)
Entity type:Individual
Prefix:MS
First Name:KELLY
Middle Name:
Last Name:VANDER MASS
Suffix:
Gender:F
Credentials:MS OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:335 CABIN RD
Mailing Address - Street 2:
Mailing Address - City:COLCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06415-1522
Mailing Address - Country:US
Mailing Address - Phone:978-891-6264
Mailing Address - Fax:
Practice Address - Street 1:465 SILAS DEANE HWY
Practice Address - Street 2:
Practice Address - City:WETHERSFIELD
Practice Address - State:CT
Practice Address - Zip Code:06109-2134
Practice Address - Country:US
Practice Address - Phone:860-721-9999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-16
Last Update Date:2015-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004520225X00000X
MA11812225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist