Provider Demographics
NPI:1679275390
Name:KELLEY-TAVARES, CHRISTINE MARIE (CPS)
Entity type:Individual
Prefix:MRS
First Name:CHRISTINE
Middle Name:MARIE
Last Name:KELLEY-TAVARES
Suffix:
Gender:F
Credentials:CPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 PAVILION AVE
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02905-1522
Mailing Address - Country:US
Mailing Address - Phone:877-827-5042
Mailing Address - Fax:
Practice Address - Street 1:66 PAVILION AVE
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02905-1522
Practice Address - Country:US
Practice Address - Phone:187-782-7504
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-20
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor