Provider Demographics
NPI:1245741982
Name:CONNOLLY, KRISTEN KELLY (LADC, MA)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:KELLY
Last Name:CONNOLLY
Suffix:
Gender:F
Credentials:LADC, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 504
Mailing Address - Street 2:
Mailing Address - City:JEFFERSONVILLE
Mailing Address - State:VT
Mailing Address - Zip Code:05464-0504
Mailing Address - Country:US
Mailing Address - Phone:802-730-2531
Mailing Address - Fax:
Practice Address - Street 1:321 S MAIN ST
Practice Address - Street 2:
Practice Address - City:SAINT ALBANS
Practice Address - State:VT
Practice Address - Zip Code:05478-6214
Practice Address - Country:US
Practice Address - Phone:802-730-2531
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-20
Last Update Date:2017-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT151.0131969101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)