Provider Demographics
NPI:1013121268
Name:KELLY, KATHLEEN MARY (LMHC)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MARY
Last Name:KELLY
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 DUNSTER PATH
Mailing Address - Street 2:
Mailing Address - City:WEST YARMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02673-1512
Mailing Address - Country:US
Mailing Address - Phone:508-862-4009
Mailing Address - Fax:
Practice Address - Street 1:60 PERSEVERANCE WAY
Practice Address - Street 2:
Practice Address - City:HYANNIS
Practice Address - State:MA
Practice Address - Zip Code:02601-1812
Practice Address - Country:US
Practice Address - Phone:508-862-9004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5110101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health