Provider Demographics
NPI:1922321538
Name:KELLY, MELISSA RAE (LICSW)
Entity Type:Individual
Prefix:MS
First Name:MELISSA
Middle Name:RAE
Last Name:KELLY
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:RAE
Other - Last Name:BOYLE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LICSW
Mailing Address - Street 1:16 BLOSSOM ST
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-3104
Mailing Address - Country:US
Mailing Address - Phone:617-726-5250
Mailing Address - Fax:
Practice Address - Street 1:16 BLOSSOM ST
Practice Address - Street 2:1ST FLOOR
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-3104
Practice Address - Country:US
Practice Address - Phone:617-726-5250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-10
Last Update Date:2011-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2151961041C0700X
MA1158091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical