Provider Demographics
NPI:1447406376
Name:KELLY, JUSTIN C
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:C
Last Name:KELLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2020 CENTRE ST
Mailing Address - Street 2:
Mailing Address - City:WEST ROXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02132-3316
Mailing Address - Country:US
Mailing Address - Phone:781-437-1323
Mailing Address - Fax:
Practice Address - Street 1:2020 CENTRE ST
Practice Address - Street 2:
Practice Address - City:WEST ROXBURY
Practice Address - State:MA
Practice Address - Zip Code:02132-3316
Practice Address - Country:US
Practice Address - Phone:781-437-1323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-12
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAM18708OtherBLUE CROSS
MA1312685Medicaid
MA1312677Medicaid
MA685661OtherTUFTS
MA1312677Medicaid