Provider Demographics
NPI:1780713735
Name:PISTACCHIO, KELLEY HARRISON (PHD)
Entity type:Individual
Prefix:DR
First Name:KELLEY
Middle Name:HARRISON
Last Name:PISTACCHIO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:KELLEY
Other - Middle Name:
Other - Last Name:HARRISON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:122 JANE ST
Mailing Address - Street 2:
Mailing Address - City:NORTH PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02904-4957
Mailing Address - Country:US
Mailing Address - Phone:401-274-6310
Mailing Address - Fax:401-421-1977
Practice Address - Street 1:610 MANTON AVE
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02909-5633
Practice Address - Country:US
Practice Address - Phone:401-274-6310
Practice Address - Fax:401-421-1977
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPS00680103T00000X, 103TB0200X, 103TC0700X, 103TC2200X, 103TM1800X, 103TP2701X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Not Answered103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
Not Answered103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI410468OtherBLUE CHIP
RIKH29823Medicaid
RI30189-1OtherBLUE CROSS
RI61-00006OtherUNITED BEHAVIORAL HEALTH