Provider Demographics
NPI:1841845468
Name:SIEGWALT, KELLY OCONNOR
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:OCONNOR
Last Name:SIEGWALT
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 1:31 MERRYFIELD LN
Mailing Address - Street 2:
Mailing Address - City:EAST HAMPSTEAD
Mailing Address - State:NH
Mailing Address - Zip Code:03826-5055
Mailing Address - Country:US
Mailing Address - Phone:603-548-3530
Mailing Address - Fax:
Practice Address - Street 1:225 CEDAR HILL ST STE 200
Practice Address - Street 2:
Practice Address - City:MARLBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01752-5900
Practice Address - Country:US
Practice Address - Phone:857-829-4040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-09
Last Update Date:2019-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NHRBT-18-59219106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician