{
"Npi": {
"NPI": "1497084081",
"EntityType": "Individual",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": "Y",
"IsOrgSubpart": null,
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": null,
"LastName": "KELLY",
"FirstName": "TERESA",
"MiddleName": "MARY",
"NamePrefix": "MS.",
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": "KELLY",
"OtherFirstName": "TERESA",
"OtherMiddleName": "M.",
"OtherNamePrefix": "MRS.",
"OtherNameSuffix": null,
"OtherCredential": "MSW",
"OtherLastNameTypeCode": "2",
"FirstLineMailingAddress": "30 STARK ST",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "NASHUA",
"MailingAddressStateName": "NH",
"MailingAddressPostalCode": "03064-6223",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "774-258-0800",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "24 LYMAN ST",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "WESTBOROUGH",
"PracticeLocationAddressStateName": "MA",
"PracticeLocationAddressPostalCode": "01581-1482",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "508-475-9110",
"PracticeLocationAddressFaxNumber": "508-422-9730",
"EnumerationDate": "12/10/2009",
"LastUpdateDate": "06/23/2020",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": "F",
"Gender": "Female",
"AuthorizedOfficialLastName": null,
"AuthorizedOfficialFirstName": null,
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": null,
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": null,
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "1041C0700X",
"TaxonomyName": "Clinical Social Worker",
"LicenseNumber": "215999",
"LicenseNumberStateCode": "MA",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}