Provider Demographics
NPI:1679703581
Name:KARL, KELLY C (PSYD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:C
Last Name:KARL
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 SUNSET HILL RD
Mailing Address - Street 2:
Mailing Address - City:WEST ROXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02132-7846
Mailing Address - Country:US
Mailing Address - Phone:617-596-4185
Mailing Address - Fax:
Practice Address - Street 1:319 LONGWOOD AVE STE 6
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-5710
Practice Address - Country:US
Practice Address - Phone:617-232-4858
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-27
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA9031103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical