Provider Demographics
NPI:1063773323
Name:HASSON, KELLY A
Entity type:Individual
Prefix:MISS
First Name:KELLY
Middle Name:A
Last Name:HASSON
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 1:80 APPLE BLOSSOM WAY
Mailing Address - Street 2:
Mailing Address - City:STOW
Mailing Address - State:MA
Mailing Address - Zip Code:01775-1388
Mailing Address - Country:US
Mailing Address - Phone:508-254-8703
Mailing Address - Fax:
Practice Address - Street 1:80 APPLE BLOSSOM WAY
Practice Address - Street 2:
Practice Address - City:STOW
Practice Address - State:MA
Practice Address - Zip Code:01775-1388
Practice Address - Country:US
Practice Address - Phone:508-254-8703
Practice Address - Fax:508-634-6984
Is Sole Proprietor?:No
Enumeration Date:2012-06-04
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
222Q00000X
MA13155-MH-CC101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist