Provider Demographics
NPI:1285705509
Name:WEBER, KELLY TAHANEY (PSYD)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:TAHANEY
Last Name:WEBER
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:KELLY
Other - Middle Name:DALE
Other - Last Name:TAHANEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:174 N QUAKER LANE
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06119
Mailing Address - Country:US
Mailing Address - Phone:860-236-1695
Mailing Address - Fax:860-236-1695
Practice Address - Street 1:300 HEBRON AVENUE
Practice Address - Street 2:SUITE 217 MEDICAL ARTS CENTER COUNSELING AFFILIATES
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033
Practice Address - Country:US
Practice Address - Phone:860-659-2697
Practice Address - Fax:860-659-3468
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002358103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
11518434OtherCAQH