Healthcare Provider Details

I. General information

NPI: 1396017117
Provider Name (Legal Business Name): MICHELLE KEESLERCONNOR LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2012
Last Update Date: 09/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

649 AMITY RD UNIT 102
BETHANY CT
06524-3091
US

IV. Provider business mailing address

20 YORK STREET SOCIAL WORK DEPARTMENT, EAST PAVILION 10-635
NEW HAVEN CT
06504-8900
US

V. Phone/Fax

Practice location:
  • Phone: 203-560-6430
  • Fax:
Mailing address:
  • Phone: 203-688-1855
  • Fax: 203-688-2395

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number007717
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: