Provider Demographics
NPI:1396481719
Name:KELLY, MICHAEL S
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:S
Last Name:KELLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 YORK ST STE 4
Mailing Address - Street 2:
Mailing Address - City:GUILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06437-2473
Mailing Address - Country:US
Mailing Address - Phone:203-453-2220
Mailing Address - Fax:
Practice Address - Street 1:34 YORK ST STE 4
Practice Address - Street 2:
Practice Address - City:GUILFORD
Practice Address - State:CT
Practice Address - Zip Code:06437-2473
Practice Address - Country:US
Practice Address - Phone:203-453-2220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-09
Last Update Date:2022-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2313106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist