Basic Information
| Provider Information | |||||||||
| NPI: | 1558778571 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLY | ||||||||
| FirstName: | MARTIN | ||||||||
| MiddleName: | AKIWANDE | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | SR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 50 REDFIELD ST | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | DORCHESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021223630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6172887450 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 50 REDFIELD ST | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | DORCHESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021223630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6172887450 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2014 | ||||||||
| LastUpdateDate: | 07/22/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.