Provider Demographics
NPI:1932313863
Name:LIM, KELLY SU (LMT, CLT)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:SU
Last Name:LIM
Suffix:
Gender:F
Credentials:LMT, CLT
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 230861
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06123-0861
Mailing Address - Country:US
Mailing Address - Phone:860-368-1648
Mailing Address - Fax:
Practice Address - Street 1:65 MEMORIAL RD
Practice Address - Street 2:SUITE 410
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06107-2434
Practice Address - Country:US
Practice Address - Phone:860-368-1648
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2013-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT6200225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1856OtherSTATE OF COLORADO MASSAGE THERAPY LICENSE