Provider Demographics
NPI:1073941522
Name:GUERTIN, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:GUERTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:433 VALLEY ST
Mailing Address - Street 2:
Mailing Address - City:WILLIMANTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06226-1901
Mailing Address - Country:US
Mailing Address - Phone:860-456-7200
Mailing Address - Fax:860-456-7202
Practice Address - Street 1:433 VALLEY ST
Practice Address - Street 2:
Practice Address - City:WILLIMANTIC
Practice Address - State:CT
Practice Address - Zip Code:06226-1901
Practice Address - Country:US
Practice Address - Phone:860-456-7200
Practice Address - Fax:860-456-7202
Is Sole Proprietor?:No
Enumeration Date:2013-10-18
Last Update Date:2013-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health