Healthcare Provider Details

I. General information

NPI: 1992088488
Provider Name (Legal Business Name): CAITLIN KELLY M.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2011
Last Update Date: 08/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13 TEMPLE ST
QUINCY MA
02169-5110
US

IV. Provider business mailing address

13 TEMPLE ST
QUINCY MA
02169-5110
US

V. Phone/Fax

Practice location:
  • Phone: 617-471-8400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: