Provider Demographics
NPI:1780364752
Name:KELLETT, CONNOR (LCSW)
Entity type:Individual
Prefix:
First Name:CONNOR
Middle Name:
Last Name:KELLETT
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 FALLS BLVD APT 5211
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169-8178
Mailing Address - Country:US
Mailing Address - Phone:508-808-2969
Mailing Address - Fax:
Practice Address - Street 1:673 BEDFORD ST
Practice Address - Street 2:
Practice Address - City:ABINGTON
Practice Address - State:MA
Practice Address - Zip Code:02351-1921
Practice Address - Country:US
Practice Address - Phone:508-808-2969
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-24
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2268711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical