Provider Demographics
NPI:1578362190
Name:ELLINGTON, KEZIAN HAVIAN
Entity type:Individual
Prefix:
First Name:KEZIAN
Middle Name:HAVIAN
Last Name:ELLINGTON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:284 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WEST SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01089-3950
Mailing Address - Country:US
Mailing Address - Phone:413-888-7249
Mailing Address - Fax:
Practice Address - Street 1:70 BROOKLINE AVE
Practice Address - Street 2:
Practice Address - City:WEST SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01089-2210
Practice Address - Country:US
Practice Address - Phone:413-612-7906
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-08
Last Update Date:2025-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5PBC77106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician