Provider Demographics
NPI:1720126246
Name:MACQUADE, KELLY S (LICSW)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:S
Last Name:MACQUADE
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:A
Other - Last Name:SCOTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:25 N STREET CIR
Mailing Address - Street 2:
Mailing Address - City:WALPOLE
Mailing Address - State:MA
Mailing Address - Zip Code:02081-3009
Mailing Address - Country:US
Mailing Address - Phone:617-797-2618
Mailing Address - Fax:
Practice Address - Street 1:105 VICTORY RD
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02122
Practice Address - Country:US
Practice Address - Phone:617-371-3010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2018-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA213235104100000X
MA1145951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker