Healthcare Provider Details

I. General information

NPI: 1801516570
Provider Name (Legal Business Name): KIMBERLY KELLY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KIMBERLY KELLY LCSW

II. Dates (important events)

Enumeration Date: 09/01/2022
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

134 STATE ST
MERIDEN CT
06450-3293
US

IV. Provider business mailing address

67 CARILLON DR UNIT A
ROCKY HILL CT
06067-2501
US

V. Phone/Fax

Practice location:
  • Phone: 860-347-6971
  • Fax: 860-343-7379
Mailing address:
  • Phone: 860-965-2690
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6238
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: