Provider Demographics
NPI:1730862707
Name:LAVALLEE, KELLI
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:LAVALLEE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KAE
Other - Middle Name:
Other - Last Name:WINTER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:83 PHENIX AVE
Mailing Address - Street 2:
Mailing Address - City:WEST WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02893-4328
Mailing Address - Country:US
Mailing Address - Phone:401-558-8008
Mailing Address - Fax:
Practice Address - Street 1:83 PHENIX AVE
Practice Address - Street 2:
Practice Address - City:WEST WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02893-4328
Practice Address - Country:US
Practice Address - Phone:401-558-8008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-08
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes102X00000XBehavioral Health & Social Service ProvidersPoetry TherapistGroup - Multi-Specialty