Provider Demographics
NPI:1962122259
Name:PAQUETTE, KELLISSA ANNE (LICSW)
Entity type:Individual
Prefix:
First Name:KELLISSA
Middle Name:ANNE
Last Name:PAQUETTE
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 TUFTS ST
Mailing Address - Street 2:
Mailing Address - City:CHARLESTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02129-2711
Mailing Address - Country:US
Mailing Address - Phone:802-238-2263
Mailing Address - Fax:
Practice Address - Street 1:15 TUFTS ST
Practice Address - Street 2:
Practice Address - City:CHARLESTOWN
Practice Address - State:MA
Practice Address - Zip Code:02129-2711
Practice Address - Country:US
Practice Address - Phone:802-238-2263
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-29
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA0001246511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical