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NPI Code Detail

MEDICARE: MRS. KELLY ANNE PETRAVICZ M.ED.

MEDICARE: MRS. KELLY ANNE PETRAVICZ M.ED.
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
11041C0700XClinical Social WorkerLICSW1141675MA

General Provider Information

NPI Number : 1710294483
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. KELLY ANNE PETRAVICZ M.ED.
Provider Business Mailing Address
First Line : 370 MERRIMACK ST BLDG 5
Second Line :
City : LAWRENCE
State : MA
Zip : 01843-1788
Country : US
Telephone Number : 978-620-0290
Fax Number :
Provider Business Practice Location Address
First Line : 370 MERRIMACK ST STE 120
Second Line :
City : LAWRENCE
State : MA
Zip : 01843-1789
Country : US
Telephone Number : 978-620-0290
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/01/2010
Last Update Date : 04/10/2026

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