Healthcare Provider Details

I. General information

NPI: 1073097788
Provider Name (Legal Business Name): KRISTEN LEE FULLER M.ED.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KRISTEN LEE KELLEY M.ED.

II. Dates (important events)

Enumeration Date: 09/18/2018
Last Update Date: 08/22/2026
Certification Date: 08/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 ERDMAN WAY STE 208
LEOMINSTER MA
01453-1840
US

IV. Provider business mailing address

80 ERDMAN WAY STE 208
LEOMINSTER MA
01453-1840
US

V. Phone/Fax

Practice location:
  • Phone: 978-870-1840
  • Fax: 978-870-1846
Mailing address:
  • Phone: 978-870-1840
  • Fax: 978-870-1846

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: