Provider Demographics
NPI:1740526672
Name:FORTIN, KELLY (MSHS)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:FORTIN
Suffix:
Gender:F
Credentials:MSHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 MIDDLEBURY RD
Mailing Address - Street 2:SUITE 213B
Mailing Address - City:MIDDLEBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06762-2500
Mailing Address - Country:US
Mailing Address - Phone:203-518-9574
Mailing Address - Fax:203-490-4242
Practice Address - Street 1:530 MIDDLEBURY RD
Practice Address - Street 2:SUITE 213B
Practice Address - City:MIDDLEBURY
Practice Address - State:CT
Practice Address - Zip Code:06762-2500
Practice Address - Country:US
Practice Address - Phone:203-518-9574
Practice Address - Fax:203-490-4242
Is Sole Proprietor?:No
Enumeration Date:2012-12-21
Last Update Date:2015-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
CT2783101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor