Healthcare Provider Details

I. General information

NPI: 1093340853
Provider Name (Legal Business Name): KELLY DIONNE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLY HAVENAR

II. Dates (important events)

Enumeration Date: 03/11/2020
Last Update Date: 03/11/2020
Certification Date: 03/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1360 TORRINGFORD ST
TORRINGTON CT
06790-3140
US

IV. Provider business mailing address

66 STARKWEATHER HILL RD
WORTHINGTON MA
01098-9607
US

V. Phone/Fax

Practice location:
  • Phone: 860-489-1008
  • Fax:
Mailing address:
  • Phone: 937-214-7667
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number4557
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: