Provider Demographics
NPI:1780020990
Name:WAWRZYNIAK, KELLY MICHELLE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:MICHELLE
Last Name:WAWRZYNIAK
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 SMYTHE ST
Mailing Address - Street 2:APT 2
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02445-7662
Mailing Address - Country:US
Mailing Address - Phone:585-820-4048
Mailing Address - Fax:
Practice Address - Street 1:85 1ST AVE
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02451-1105
Practice Address - Country:US
Practice Address - Phone:781-647-7246
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-14
Last Update Date:2013-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA9672103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical