Provider Demographics
NPI:1073282299
Name:KELLY, KATHRYN (LPC, CLAT)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:LPC, CLAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:219 FOUNTAIN ST APT 10
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06515-1983
Mailing Address - Country:US
Mailing Address - Phone:203-444-7040
Mailing Address - Fax:
Practice Address - Street 1:291 S LAMBERT RD STE 2
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CT
Practice Address - Zip Code:06477-3559
Practice Address - Country:US
Practice Address - Phone:475-414-6307
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-10
Last Update Date:2023-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT53221700000X
CT006241101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT52OtherCT DPH
CT006241OtherDEPARTMENT OF PUBLIC HEALTH