Provider Demographics
NPI:1801511159
Name:KELLY, ALYSSA ANNE (LCSW)
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:ANNE
Last Name:KELLY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 BRITTON AVE
Mailing Address - Street 2:
Mailing Address - City:STOUGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02072-2502
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:175 PARAMOUNT DR UNIT 102
Practice Address - Street 2:
Practice Address - City:RAYNHAM
Practice Address - State:MA
Practice Address - Zip Code:02767-1066
Practice Address - Country:US
Practice Address - Phone:508-324-5525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-10
Last Update Date:2022-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA228331104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA228331OtherASWB