Healthcare Provider Details

I. General information

NPI: 1770375495
Provider Name (Legal Business Name): SELIN KELLY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2025
Last Update Date: 12/05/2025
Certification Date: 12/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1058 PECK LN
CHESHIRE CT
06410-1531
US

IV. Provider business mailing address

1058 PECK LN
CHESHIRE CT
06410-1531
US

V. Phone/Fax

Practice location:
  • Phone: 475-303-5494
  • Fax:
Mailing address:
  • Phone: 475-303-5494
  • Fax: 475-275-7227

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number15213
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: