Provider Demographics
NPI:1972081792
Name:FARRELL, KELLY RYLE
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:RYLE
Last Name:FARRELL
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 1:267 BUNKER HILL ST # 1
Mailing Address - Street 2:
Mailing Address - City:CHARLESTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02129-1834
Mailing Address - Country:US
Mailing Address - Phone:202-669-4352
Mailing Address - Fax:
Practice Address - Street 1:178 SAVIN ST STE 300
Practice Address - Street 2:
Practice Address - City:MALDEN
Practice Address - State:MA
Practice Address - Zip Code:02148-2329
Practice Address - Country:US
Practice Address - Phone:781-338-7866
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-02
Last Update Date:2018-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1180941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical