Provider Demographics
NPI:1831463132
Name:RADOCCHIA, KELLY M (LCSW, LADC, CAC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:M
Last Name:RADOCCHIA
Suffix:
Gender:F
Credentials:LCSW, LADC, CAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 OAKLAND RD
Mailing Address - Street 2:UNIT 106
Mailing Address - City:SOUTH WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06074-2866
Mailing Address - Country:US
Mailing Address - Phone:860-646-0300
Mailing Address - Fax:
Practice Address - Street 1:140 GLASTONBURY BLVD
Practice Address - Street 2:SUITE 25
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-4402
Practice Address - Country:US
Practice Address - Phone:860-644-0300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-05
Last Update Date:2012-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0049391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical