Healthcare Provider Details

I. General information

NPI: 1710733688
Provider Name (Legal Business Name): KELLI O'CONNOR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2024
Last Update Date: 07/31/2024
Certification Date: 07/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 BOSTON AVE STE 1925
MEDFORD MA
02155-4243
US

IV. Provider business mailing address

121 MAIN ST APT 2
WOBURN MA
01801-5644
US

V. Phone/Fax

Practice location:
  • Phone: 617-869-1324
  • Fax:
Mailing address:
  • Phone: 617-869-1324
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: