Healthcare Provider Details

I. General information

NPI: 1912551276
Provider Name (Legal Business Name): KELLY A O'MALLEY PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2019
Last Update Date: 09/09/2026
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

165 MAIN STREET SUITE 203
MEDWAY MA
02053
US

IV. Provider business mailing address

165 MAIN STREET SUITE 203
MEDWAY MA
02053
US

V. Phone/Fax

Practice location:
  • Phone: 774-573-0362
  • Fax:
Mailing address:
  • Phone: 774-573-0362
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number11093
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: