Provider Demographics
NPI:1427224815
Name:KELLY, CRAIG THOMAS (LAC)
Entity Type:Individual
Prefix:MR
First Name:CRAIG
Middle Name:THOMAS
Last Name:KELLY
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 PINE DR
Mailing Address - Street 2:
Mailing Address - City:ELLINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06029-3508
Mailing Address - Country:US
Mailing Address - Phone:860-550-0242
Mailing Address - Fax:
Practice Address - Street 1:6 PINE DR
Practice Address - Street 2:
Practice Address - City:ELLINGTON
Practice Address - State:CT
Practice Address - Zip Code:06029-3508
Practice Address - Country:US
Practice Address - Phone:860-550-0242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-05
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000329171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist