Provider Demographics
NPI:1023498565
Name:KELLY, COLLEEN EMMA (MA, BCBA)
Entity type:Individual
Prefix:MRS
First Name:COLLEEN
Middle Name:EMMA
Last Name:KELLY
Suffix:
Gender:F
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:COLLEEN
Other - Middle Name:EMMA
Other - Last Name:LEAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, BCBA
Mailing Address - Street 1:48 ABERDEEN RD
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02476-5752
Mailing Address - Country:US
Mailing Address - Phone:774-644-6276
Mailing Address - Fax:
Practice Address - Street 1:48 ABERDEEN RD
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:MA
Practice Address - Zip Code:02476-5752
Practice Address - Country:US
Practice Address - Phone:774-644-6276
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-29
Last Update Date:2015-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA11212433103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst