Healthcare Provider Details

I. General information

NPI: 1255147195
Provider Name (Legal Business Name): KELLY LYNN VIERA LIFE COACH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2024
Last Update Date: 12/05/2024
Certification Date: 12/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 RIVERFORD RD
BROOKFIELD CT
06804-1316
US

IV. Provider business mailing address

24 RIVERFORD RD
BROOKFIELD CT
06804-1316
US

V. Phone/Fax

Practice location:
  • Phone: 203-512-1702
  • Fax:
Mailing address:
  • Phone: 203-512-1702
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: