Provider Demographics
NPI:1659354751
Name:KENNELLY, AMY LISA (LCSW)
Entity Type:Individual
Prefix:MS
First Name:AMY
Middle Name:LISA
Last Name:KENNELLY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 BRIAR CT
Mailing Address - Street 2:
Mailing Address - City:CHESHIRE
Mailing Address - State:CT
Mailing Address - Zip Code:06410-3903
Mailing Address - Country:US
Mailing Address - Phone:203-271-1242
Mailing Address - Fax:
Practice Address - Street 1:64 ROBBINS ST
Practice Address - Street 2:CRISIS INTERVENTION
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-2613
Practice Address - Country:US
Practice Address - Phone:203-573-6500
Practice Address - Fax:203-573-7007
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0039561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical