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General NPI Number Information
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NPI Number | 1124349998
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Entity Type | Organization
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Legal Business Name | KELLY COLLABORATIVE CARE, INC
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Dates
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Enumeration Date | 06/16/2010
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Last Update Date | 12/13/2010
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Provider Practice Location Address
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Address Line | 616 ROUTE 6A
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City | DENNIS
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State | MA
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Zip | 02638-1906
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Country | US
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Telephone | 773-487-7647
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Fax |
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Provider Business Mailing Address
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Address Line | 180 OLD RED TOP RD
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City | BREWSTER
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State | MA
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Zip | 02631-2370
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Country | US
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Telephone | 774-487-7647
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MARY HETTICH-KELLY
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Credential | FNP-BC, RNCS
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Telephone | 774-487-7647
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 197116
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License Number State | MA
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