Provider Demographics
NPI:1821591587
Name:STOCKHAUS, KELLEY
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:
Last Name:STOCKHAUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLEY
Other - Middle Name:
Other - Last Name:DICKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11 MEETING HOUSE LN
Mailing Address - Street 2:
Mailing Address - City:MILLBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01527-3965
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 STATE ST
Practice Address - Street 2:
Practice Address - City:FRAMINGHAM
Practice Address - State:MA
Practice Address - Zip Code:01702-2499
Practice Address - Country:US
Practice Address - Phone:508-626-4564
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-08
Last Update Date:2018-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA24452255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer