Provider Demographics
NPI:1013420025
Name:JEANINE KELO, LPC, LLC
Entity Type:Organization
Organization Name:JEANINE KELO, LPC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JEANINE
Authorized Official - Middle Name:
Authorized Official - Last Name:KELO
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:860-949-5455
Mailing Address - Street 1:225 PROVIDENCE PIKE
Mailing Address - Street 2:
Mailing Address - City:PUTNAM
Mailing Address - State:CT
Mailing Address - Zip Code:06260-2526
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:225 PROVIDENCE PIKE
Practice Address - Street 2:
Practice Address - City:PUTNAM
Practice Address - State:CT
Practice Address - Zip Code:06260-2526
Practice Address - Country:US
Practice Address - Phone:860-949-5455
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-13
Last Update Date:2017-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003256101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty