Provider Demographics
NPI:1154473247
Name:MADIN, KELLY V (LMFT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:V
Last Name:MADIN
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:V
Other - Last Name:VAUGHN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:42 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:TORRINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06790
Mailing Address - Country:US
Mailing Address - Phone:860-626-1112
Mailing Address - Fax:860-626-1118
Practice Address - Street 1:42 CHURCH ST
Practice Address - Street 2:
Practice Address - City:TORRINGTON
Practice Address - State:CT
Practice Address - Zip Code:06790
Practice Address - Country:US
Practice Address - Phone:860-626-1112
Practice Address - Fax:860-626-1118
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001191106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist