Provider Demographics
NPI:1306963764
Name:ECSEDY, KELLY
Entity type:Individual
Prefix:MS
First Name:KELLY
Middle Name:
Last Name:ECSEDY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:254 TRIANGLE BLVD
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06762-3331
Mailing Address - Country:US
Mailing Address - Phone:203-598-7546
Mailing Address - Fax:
Practice Address - Street 1:22 TOMPKINS ST
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-1417
Practice Address - Country:US
Practice Address - Phone:203-419-0381
Practice Address - Fax:203-419-0389
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000643224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant