Provider Demographics
NPI:1922403955
Name:KELLY, KIMBERLY C (MED, BCBA)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:C
Last Name:KELLY
Suffix:
Gender:F
Credentials:MED, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 CUMMINGS CTR
Mailing Address - Street 2:157J
Mailing Address - City:BEVERLY
Mailing Address - State:MA
Mailing Address - Zip Code:01915-6115
Mailing Address - Country:US
Mailing Address - Phone:978-969-6019
Mailing Address - Fax:
Practice Address - Street 1:62 LOWELL ST STE 5
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03101-1607
Practice Address - Country:US
Practice Address - Phone:603-664-4411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-04
Last Update Date:2019-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst