Basic Information
| Provider Information | |||||||||
| NPI: | 1699397828 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLY | ||||||||
| FirstName: | ASHLEY | ||||||||
| MiddleName: | LAUREN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 103 COMMERCIAL ST | ||||||||
| Address2: | |||||||||
| City: | BROCKTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023023133 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 103 COMMERCIAL ST | ||||||||
| Address2: | |||||||||
| City: | BROCKTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023023133 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5085804691 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2020 | ||||||||
| LastUpdateDate: | 05/11/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.