Healthcare Provider Details

I. General information

NPI: 1093844193
Provider Name (Legal Business Name): SUSAN R KELLEY M.ED.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 TER HEUN DR
FALMOUTH MA
02540-2525
US

IV. Provider business mailing address

128 LOCUST ST
FALMOUTH MA
02540-2659
US

V. Phone/Fax

Practice location:
  • Phone: 508-540-6550
  • Fax: 508-540-7480
Mailing address:
  • Phone: 508-540-3363
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberPENDING
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: