Provider Demographics
NPI:1871641035
Name:DEALY, KEVIN JOHN (LICSW)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:JOHN
Last Name:DEALY
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95 COLONIAL WAY
Mailing Address - Street 2:
Mailing Address - City:NORTH ATTLEBORO
Mailing Address - State:MA
Mailing Address - Zip Code:02760-2833
Mailing Address - Country:US
Mailing Address - Phone:508-695-2770
Mailing Address - Fax:508-695-2770
Practice Address - Street 1:95 COLONIAL WAY
Practice Address - Street 2:
Practice Address - City:NORTH ATTLEBORO
Practice Address - State:MA
Practice Address - Zip Code:02760-2833
Practice Address - Country:US
Practice Address - Phone:508-695-2770
Practice Address - Fax:508-695-2770
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1048761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIISW 00591OtherSTAYE LICENSE
MA104876OtherSTATE LICENSE
7507176Medicare UPIN
MAPO3056Medicare UPIN
RI000599Medicare UPIN
RIISW 00591OtherSTAYE LICENSE
RI1022980Medicare UPIN
62-65552Medicare UPIN
344090Medicare UPIN
MA104876OtherSTATE LICENSE
RI30685-0Medicare UPIN
RI04312912602Medicare UPIN
005838Medicare UPIN