Healthcare Provider Details

I. General information

NPI: 1649092883
Provider Name (Legal Business Name): MRS. KELLY ELIZABETH CICHOCKI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/29/2024
Last Update Date: 10/29/2024
Certification Date: 10/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 MAIN ST
HULL MA
02045-1017
US

IV. Provider business mailing address

108 MAIN ST
HULL MA
02045-1017
US

V. Phone/Fax

Practice location:
  • Phone: 617-922-8880
  • Fax:
Mailing address:
  • Phone: 617-922-8880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number4033
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: