Provider Demographics
NPI:1336398437
Name:QUINN, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:QUINN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 MULBERRY ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01105-1433
Mailing Address - Country:US
Mailing Address - Phone:413-739-2440
Mailing Address - Fax:413-739-2513
Practice Address - Street 1:15 MULBERRY ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01105-1433
Practice Address - Country:US
Practice Address - Phone:413-739-2440
Practice Address - Fax:413-739-2513
Is Sole Proprietor?:No
Enumeration Date:2008-09-12
Last Update Date:2010-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
MA216260101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker