Provider Demographics
NPI:1811434855
Name:RACICOT, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:RACICOT
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 1:6E SUMMER ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01944-1579
Mailing Address - Country:US
Mailing Address - Phone:774-278-0919
Mailing Address - Fax:
Practice Address - Street 1:800 CUMMINGS CTR STE 364U
Practice Address - Street 2:
Practice Address - City:BEVERLY
Practice Address - State:MA
Practice Address - Zip Code:01915-6174
Practice Address - Country:US
Practice Address - Phone:774-278-0920
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-29
Last Update Date:2017-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program