Provider Demographics
NPI:1780006171
Name:POITRAS, KELLEY MARIE
Entity Type:Individual
Prefix:MS
First Name:KELLEY
Middle Name:MARIE
Last Name:POITRAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 92
Mailing Address - Street 2:
Mailing Address - City:SOUTH WALPOLE
Mailing Address - State:MA
Mailing Address - Zip Code:02071-0092
Mailing Address - Country:US
Mailing Address - Phone:508-369-2060
Mailing Address - Fax:
Practice Address - Street 1:122 GROVE ST
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:MA
Practice Address - Zip Code:02038-2180
Practice Address - Country:US
Practice Address - Phone:508-455-6208
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-20
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
222Q00000X
MA510103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist