Healthcare Provider Details

I. General information

NPI: 1992158604
Provider Name (Legal Business Name): EMILY KELLY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2016
Last Update Date: 07/30/2025
Certification Date: 07/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 N MAIN ST STE SUITE80
BRISTOL CT
06010-4926
US

IV. Provider business mailing address

225 N MAIN ST STE 80
BRISTOL CT
06010-4926
US

V. Phone/Fax

Practice location:
  • Phone: 860-506-7905
  • Fax:
Mailing address:
  • Phone: 413-285-3274
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number068.0136426
License Number StateVT
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number003551
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: