Provider Demographics
NPI:1326573312
Name:KELLY, MICHELE (LCSW/ LICSW)
Entity type:Individual
Prefix:
First Name:MICHELE
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:LCSW/ LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 BITGOOD RD
Mailing Address - Street 2:
Mailing Address - City:JEWETT CITY
Mailing Address - State:CT
Mailing Address - Zip Code:06351-1503
Mailing Address - Country:US
Mailing Address - Phone:860-576-7834
Mailing Address - Fax:
Practice Address - Street 1:12 CASE ST STE 302
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:CT
Practice Address - Zip Code:06360-2222
Practice Address - Country:US
Practice Address - Phone:860-294-9777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-27
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIISW036411041C0700X
CT97741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical