Provider Demographics
NPI:1467110767
Name:KELLY, BRANDON CONOR (LMSW)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:CONOR
Last Name:KELLY
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:358 EDGEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-4082
Mailing Address - Country:US
Mailing Address - Phone:203-435-6887
Mailing Address - Fax:
Practice Address - Street 1:358 EDGEWOOD AVE
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-4082
Practice Address - Country:US
Practice Address - Phone:203-435-6887
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-03
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT6225104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker