Provider Demographics
NPI:1164943478
Name:WHITTAKER, KELLEY ANNE (MA, CAS, LPC)
Entity Type:Individual
Prefix:MS
First Name:KELLEY
Middle Name:ANNE
Last Name:WHITTAKER
Suffix:
Gender:F
Credentials:MA, CAS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1106 TROUT BROOK DR
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06119-1246
Mailing Address - Country:US
Mailing Address - Phone:860-670-3623
Mailing Address - Fax:
Practice Address - Street 1:3 BARNARD LN
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:CT
Practice Address - Zip Code:06002-2452
Practice Address - Country:US
Practice Address - Phone:860-670-3623
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-28
Last Update Date:2017-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT3210101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional