Provider Demographics
NPI:1316034739
Name:REDDICK, KELLY (LMFT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:REDDICK
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49 BLUE HILL RD
Mailing Address - Street 2:
Mailing Address - City:BOZRAH
Mailing Address - State:CT
Mailing Address - Zip Code:06334-1001
Mailing Address - Country:US
Mailing Address - Phone:860-823-1399
Mailing Address - Fax:
Practice Address - Street 1:219 W TOWN ST STE D
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:CT
Practice Address - Zip Code:06360-2130
Practice Address - Country:US
Practice Address - Phone:860-208-1200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001106106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTD80821Medicare UPIN