Provider Demographics
NPI:1912551276
Name:O'MALLEY, KELLY (PHD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:
Last Name:O'MALLEY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 LARKIN LN
Mailing Address - Street 2:
Mailing Address - City:HOPEDALE
Mailing Address - State:MA
Mailing Address - Zip Code:01747-1436
Mailing Address - Country:US
Mailing Address - Phone:719-534-3230
Mailing Address - Fax:
Practice Address - Street 1:940 BELMONT ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-5596
Practice Address - Country:US
Practice Address - Phone:719-534-3230
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-25
Last Update Date:2019-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA11093103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical