Provider Demographics
NPI:1790223501
Name:REARDON, KERI ANNE (LICSW)
Entity Type:Individual
Prefix:
First Name:KERI
Middle Name:ANNE
Last Name:REARDON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 ALDRIN RD STE 2
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02360-4814
Mailing Address - Country:US
Mailing Address - Phone:774-404-7859
Mailing Address - Fax:774-773-9045
Practice Address - Street 1:5 ALDRIN RD STE 2
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02360-4814
Practice Address - Country:US
Practice Address - Phone:774-404-7859
Practice Address - Fax:774-773-9045
Is Sole Proprietor?:No
Enumeration Date:2017-02-01
Last Update Date:2017-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1198121041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical