Provider Demographics
NPI:1255416590
Name:BRANSFORD, KELLIE SMITH (LICSW)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:SMITH
Last Name:BRANSFORD
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:KELLIE
Other - Middle Name:PATRICIA
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LICSW
Mailing Address - Street 1:41 MALL RD
Mailing Address - Street 2:LAHEY CLINIC, INC.
Mailing Address - City:BURLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:01805-0001
Mailing Address - Country:US
Mailing Address - Phone:781-744-8925
Mailing Address - Fax:
Practice Address - Street 1:41 MALL RD
Practice Address - Street 2:LAHEY CLINIC, INC.
Practice Address - City:BURLINGTON
Practice Address - State:MA
Practice Address - Zip Code:01805-0001
Practice Address - Country:US
Practice Address - Phone:781-744-8925
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1114071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP2322301Medicare PIN