Provider Demographics
NPI:1215081526
Name:KELLY, SEAN F (PHD)
Entity type:Individual
Prefix:DR
First Name:SEAN
Middle Name:F
Last Name:KELLY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 WOODLAND RD
Mailing Address - Street 2:
Mailing Address - City:BEVERLY
Mailing Address - State:MA
Mailing Address - Zip Code:01915-2747
Mailing Address - Country:US
Mailing Address - Phone:617-792-7479
Mailing Address - Fax:
Practice Address - Street 1:20 PARK PLZ
Practice Address - Street 2:SUITE 452
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02116-4303
Practice Address - Country:US
Practice Address - Phone:617-792-7479
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2016-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1698103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0504513Medicaid
MAW01759OtherBLUE SHIELD PROVIDER ID
MAW0175925793OtherTRICARE
MAR43430Medicare UPIN
MAW0175925793OtherTRICARE