Provider Demographics
NPI:1265926141
Name:KELLEY, MINA ALEXANDRA (BA)
Entity type:Individual
Prefix:
First Name:MINA
Middle Name:ALEXANDRA
Last Name:KELLEY
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 BUNNY LN
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:CT
Mailing Address - Zip Code:06234-3302
Mailing Address - Country:US
Mailing Address - Phone:860-942-3705
Mailing Address - Fax:
Practice Address - Street 1:354 WAVERLY ST
Practice Address - Street 2:
Practice Address - City:FRAMINGHAM
Practice Address - State:MA
Practice Address - Zip Code:01702
Practice Address - Country:US
Practice Address - Phone:508-661-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-14
Last Update Date:2018-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT148940150106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician