Provider Demographics
NPI:1386192086
Name:SWARTZ, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:SWARTZ
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 1:144 KNIGHT LN APT 307
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:VT
Mailing Address - Zip Code:05495-9315
Mailing Address - Country:US
Mailing Address - Phone:203-988-4429
Mailing Address - Fax:
Practice Address - Street 1:144 KNIGHT LN APT 307
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:VT
Practice Address - Zip Code:05495-9315
Practice Address - Country:US
Practice Address - Phone:203-988-4429
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-12
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA13003287Medicaid
MA99618201OtherNETWORK HEALTH
MA042611055OtherTAX ID
MA1004745OtherNHP
MA0000023532OtherBMC
MA1303287OtherMBHP
MAM18633OtherBCBS