Provider Demographics
NPI: | 1497209167 |
---|---|
Name: | MEANY, KELLY (LMSW, LADC) |
Entity Type: | Individual |
Prefix: | |
First Name: | KELLY |
Middle Name: | |
Last Name: | MEANY |
Suffix: | |
Gender: | F |
Credentials: | LMSW, LADC |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 30 OLD KINGS HWY RD |
Mailing Address - Street 2: | |
Mailing Address - City: | DANEN |
Mailing Address - State: | CT |
Mailing Address - Zip Code: | 06820 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 203-984-1994 |
Mailing Address - Fax: | 703-202-2209 |
Practice Address - Street 1: | 30 OLD KINGS HWY RD |
Practice Address - Street 2: | |
Practice Address - City: | DANEN |
Practice Address - State: | CT |
Practice Address - Zip Code: | 06820 |
Practice Address - Country: | US |
Practice Address - Phone: | 203-984-1994 |
Practice Address - Fax: | 703-202-2209 |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2016-08-10 |
Last Update Date: | 2021-09-02 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
CT | 1330 | 101YA0400X |
NY | 098303 | 171M00000X |
CT | 11495 | 1041C0700X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 1041C0700X | Behavioral Health & Social Service Providers | Social Worker | Clinical | |
No | 101YA0400X | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | Group - Multi-Specialty |
No | 171M00000X | Other Service Providers | Case Manager/Care Coordinator |