Healthcare Provider Details

I. General information

NPI: 1497209167
Provider Name (Legal Business Name): KELLY MEANY LMSW, LADC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2016
Last Update Date: 09/02/2021
Certification Date: 09/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 OLD KINGS HWY RD
DANEN CT
06820
US

IV. Provider business mailing address

30 OLD KINGS HWY RD
DANEN CT
06820
US

V. Phone/Fax

Practice location:
  • Phone: 203-984-1994
  • Fax: 703-202-2209
Mailing address:
  • Phone: 203-984-1994
  • Fax: 703-202-2209

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1330
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number098303
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number11495
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: