Provider Demographics
NPI:1184950032
Name:KELLY, DAVID E (LCSW)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:E
Last Name:KELLY
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 MOTT AVE
Mailing Address - Street 2:SUITE 2E
Mailing Address - City:NORWALK
Mailing Address - State:CT
Mailing Address - Zip Code:06850-3320
Mailing Address - Country:US
Mailing Address - Phone:203-505-8782
Mailing Address - Fax:
Practice Address - Street 1:10 MOTT AVE
Practice Address - Street 2:SUITE 2E
Practice Address - City:NORWALK
Practice Address - State:CT
Practice Address - Zip Code:06850-3320
Practice Address - Country:US
Practice Address - Phone:203-505-8782
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-28
Last Update Date:2010-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0069891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTD300010821Medicare PIN