Provider Demographics
NPI:1780484048
Name:KELLY, BRYAN (LMFT)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:KELLY
Suffix:
Gender:
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 SPRING ST APT 3
Mailing Address - Street 2:
Mailing Address - City:NAUGATUCK
Mailing Address - State:CT
Mailing Address - Zip Code:06770-2940
Mailing Address - Country:US
Mailing Address - Phone:757-427-4047
Mailing Address - Fax:
Practice Address - Street 1:260 SPRING ST APT 3
Practice Address - Street 2:
Practice Address - City:NAUGATUCK
Practice Address - State:CT
Practice Address - Zip Code:06770-2940
Practice Address - Country:US
Practice Address - Phone:631-566-2934
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-17
Last Update Date:2025-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002629106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist