Provider Demographics
NPI:1457782245
Name:GANDOLFO, KELLY (MS, BCBA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:GANDOLFO
Suffix:
Gender:F
Credentials:MS, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:256 TRAILSIDE WAY
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:MA
Mailing Address - Zip Code:01721-2356
Mailing Address - Country:US
Mailing Address - Phone:508-395-7598
Mailing Address - Fax:
Practice Address - Street 1:256 TRAILSIDE WAY
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:MA
Practice Address - Zip Code:01721-2356
Practice Address - Country:US
Practice Address - Phone:508-395-7598
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-05
Last Update Date:2013-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1-13-14104103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst