Provider Demographics
NPI:1013976703
Name:MASSUCCI, KELLY A (MED OTR/L)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:A
Last Name:MASSUCCI
Suffix:
Gender:F
Credentials:MED OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 FOXCROFT RD
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06119-1018
Mailing Address - Country:US
Mailing Address - Phone:860-523-8677
Mailing Address - Fax:
Practice Address - Street 1:270 FARMINGTON AVE
Practice Address - Street 2:SUITE 126
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06032-1909
Practice Address - Country:US
Practice Address - Phone:860-674-1824
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002268174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT00424493500Medicaid
CT3623042OtherAETNA
CT13002268CT01Medicare UPIN
CT3623042OtherAETNA