Provider Demographics
NPI:1629340823
Name:SGROI, KELLEY (LYNC)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:
Last Name:SGROI
Suffix:
Gender:F
Credentials:LYNC
Other - Prefix:
Other - First Name:KELLEY
Other - Middle Name:
Other - Last Name:SGROI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMHC
Mailing Address - Street 1:252 W MARION AVE
Mailing Address - Street 2:# 1134
Mailing Address - City:PUNTA GORDA
Mailing Address - State:FL
Mailing Address - Zip Code:33950-4442
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17 S HIGHLAND ST
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06119-1826
Practice Address - Country:US
Practice Address - Phone:860-258-4171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-02
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003449101YP2500X
CT005958124Q00000X
FLMH17027101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1629340823Medicaid