Provider Demographics
NPI:1154888717
Name:KELLY-DETWILER, JULIE
Entity type:Individual
Prefix:
First Name:JULIE
Middle Name:
Last Name:KELLY-DETWILER
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 1:400 WASHINGTON ST STE 303
Mailing Address - Street 2:
Mailing Address - City:BRAINTREE
Mailing Address - State:MA
Mailing Address - Zip Code:02184-4768
Mailing Address - Country:US
Mailing Address - Phone:781-871-6550
Mailing Address - Fax:
Practice Address - Street 1:384 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:NORWELL
Practice Address - State:MA
Practice Address - Zip Code:02061-2010
Practice Address - Country:US
Practice Address - Phone:781-871-6550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-01
Last Update Date:2019-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor