Provider Demographics
NPI:1104653344
Name:KELLY A. SCHMIDT, PH.D., LLC
Entity type:Organization
Organization Name:KELLY A. SCHMIDT, PH.D., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:A
Authorized Official - Last Name:SCHMIDT
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:860-871-5402
Mailing Address - Street 1:16 MAIN ST.
Mailing Address - Street 2:
Mailing Address - City:ELLINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06029-0061
Mailing Address - Country:US
Mailing Address - Phone:860-871-5402
Mailing Address - Fax:860-871-5413
Practice Address - Street 1:16 MAIN ST.
Practice Address - Street 2:
Practice Address - City:ELLINGTON
Practice Address - State:CT
Practice Address - Zip Code:06029-0061
Practice Address - Country:US
Practice Address - Phone:860-871-5402
Practice Address - Fax:860-871-5413
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-19
Last Update Date:2024-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008093888Medicaid