Provider Demographics
NPI:1144633645
Name:TESSIER, KELLEY
Entity type:Individual
Prefix:
First Name:KELLEY
Middle Name:
Last Name:TESSIER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 CORNELIA CT UNIT 104
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:VT
Mailing Address - Zip Code:05468-4657
Mailing Address - Country:US
Mailing Address - Phone:802-274-8116
Mailing Address - Fax:844-742-8384
Practice Address - Street 1:28 CORNELIA CT UNIT 104
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:VT
Practice Address - Zip Code:05468-4657
Practice Address - Country:US
Practice Address - Phone:802-274-8116
Practice Address - Fax:844-742-8384
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-03
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT151.0125376101YA0400X
VT068.0100151101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1026417Medicaid
VT1025703Medicaid