Healthcare Provider Details

I. General information

NPI: 1487219507
Provider Name (Legal Business Name): KELITA APOLONIA LUGG LCSW, LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2019
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

304 W MAIN ST
AVON CT
06001-4355
US

IV. Provider business mailing address

304 W MAIN ST
AVON CT
06001-4355
US

V. Phone/Fax

Practice location:
  • Phone: 999-999-9999
  • Fax:
Mailing address:
  • Phone: 999-999-9999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC26431
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number17077
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number106266
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: