Provider Demographics
NPI:1700661741
Name:KELLY, ELISABETH GRACE (MFT, LMFT-A)
Entity Type:Individual
Prefix:MRS
First Name:ELISABETH
Middle Name:GRACE
Last Name:KELLY
Suffix:
Gender:F
Credentials:MFT, LMFT-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 FORTY ACRE MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06811-3353
Mailing Address - Country:US
Mailing Address - Phone:203-240-0385
Mailing Address - Fax:
Practice Address - Street 1:66 FORTY ACRE MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06811-3353
Practice Address - Country:US
Practice Address - Phone:203-240-0385
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-28
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT3224106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist