Provider Demographics
NPI:1659086965
Name:ESPINOSA, KELLY L
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:L
Last Name:ESPINOSA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 WATERSIDE XING STE 401
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06095-1588
Mailing Address - Country:US
Mailing Address - Phone:860-731-5522
Mailing Address - Fax:860-731-5536
Practice Address - Street 1:391 POMFRET ST
Practice Address - Street 2:
Practice Address - City:PUTNAM
Practice Address - State:CT
Practice Address - Zip Code:06260-1852
Practice Address - Country:US
Practice Address - Phone:877-884-3571
Practice Address - Fax:860-731-5536
Is Sole Proprietor?:No
Enumeration Date:2023-01-20
Last Update Date:2023-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CT41416164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health