Provider Demographics
NPI:1821384207
Name:KELLEY GEMMA, LLC DBA OCEAN STATE PSYCHOTHERAPY, INC.
Entity Type:Organization
Organization Name:KELLEY GEMMA, LLC DBA OCEAN STATE PSYCHOTHERAPY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KELLEY
Authorized Official - Middle Name:E
Authorized Official - Last Name:GEMMA
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:401-268-3886
Mailing Address - Street 1:1130 TEN ROD RD
Mailing Address - Street 2:SUITE F 203
Mailing Address - City:NORTH KINGSTOWN
Mailing Address - State:RI
Mailing Address - Zip Code:02852-4161
Mailing Address - Country:US
Mailing Address - Phone:401-268-3886
Mailing Address - Fax:401-268-3887
Practice Address - Street 1:1130 TEN ROD RD
Practice Address - Street 2:SUITE F 203
Practice Address - City:NORTH KINGSTOWN
Practice Address - State:RI
Practice Address - Zip Code:02852-4161
Practice Address - Country:US
Practice Address - Phone:401-268-3886
Practice Address - Fax:401-268-3887
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-23
Last Update Date:2011-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIISW001777101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI809082008Medicare UPIN