MEDICARE: BRIAN KELLY LICSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	1029609	MA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	699909	OTHER	MA	TUFTS
2	P07461	OTHER	MA	BCBS

General Provider Information

NPI Number	:	1598832479
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRIAN KELLY LICSW

Provider Business Mailing Address
First Line	:	7 PENNSYLVANIA AVE
Second Line	:
City	:	NEWTON
State	:	MA
Zip	:	02464-1357
Country	:	US
Telephone Number	:	774-306-6540
Fax Number	:

Provider Business Practice Location Address
First Line	:	7 PENNSYLVANIA AVE
Second Line	:
City	:	NEWTON
State	:	MA
Zip	:	02464-1357
Country	:	US
Telephone Number	:	774-306-6540
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/29/2006
Last Update Date	:	04/08/2025

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