Healthcare Provider Details

I. General information

NPI: 1811491822
Provider Name (Legal Business Name): KELLY ANN WHITE M.ED.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2018
Last Update Date: 12/21/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 MOON ISLAND RD
QUINCY MA
02171-1034
US

IV. Provider business mailing address

74 REED ST
RANDOLPH MA
02368-2516
US

V. Phone/Fax

Practice location:
  • Phone: 781-684-9044
  • Fax:
Mailing address:
  • Phone: 781-684-9044
  • Fax: 617-847-0915

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: