Provider Demographics
NPI:1720506462
Name:KELO, JEANINE (LPC)
Entity Type:Individual
Prefix:
First Name:JEANINE
Middle Name:
Last Name:KELO
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 20
Mailing Address - Street 2:
Mailing Address - City:PUTNAM
Mailing Address - State:CT
Mailing Address - Zip Code:06260-0020
Mailing Address - Country:US
Mailing Address - Phone:860-949-5455
Mailing Address - Fax:
Practice Address - Street 1:245 MAIN ST
Practice Address - Street 2:
Practice Address - City:DANIELSON
Practice Address - State:CT
Practice Address - Zip Code:06239-2816
Practice Address - Country:US
Practice Address - Phone:860-949-5455
Practice Address - Fax:866-209-6522
Is Sole Proprietor?:No
Enumeration Date:2017-09-01
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT3256101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional