Provider Demographics
NPI:1710733688
Name:O'CONNOR, KELLI
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:O'CONNOR
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 1:121 MAIN ST APT 2
Mailing Address - Street 2:
Mailing Address - City:WOBURN
Mailing Address - State:MA
Mailing Address - Zip Code:01801-5644
Mailing Address - Country:US
Mailing Address - Phone:617-869-1324
Mailing Address - Fax:
Practice Address - Street 1:200 BOSTON AVE STE 1925
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-4243
Practice Address - Country:US
Practice Address - Phone:617-869-1324
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-30
Last Update Date:2024-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool