Healthcare Provider Details

I. General information

NPI: 1821753658
Provider Name (Legal Business Name): KRYSTAL KELLY LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2021
Last Update Date: 07/03/2026
Certification Date: 07/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 REGENCY DR STE 101
BLOOMFIELD CT
06002-2310
US

IV. Provider business mailing address

27 HOLMES DR
WINDSOR CT
06095-3969
US

V. Phone/Fax

Practice location:
  • Phone: 860-905-4776
  • Fax:
Mailing address:
  • Phone: 860-778-5015
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number004885
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number004885
License Number StateCT
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number004885
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: