Healthcare Provider Details

I. General information

NPI: 1841646742
Provider Name (Legal Business Name): KELLEY M KENDALL LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2016
Last Update Date: 09/22/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

731 MAIN STREET SUITE 122
MONROE CT
06468
US

IV. Provider business mailing address

56 MEADOWVIEW DRIVE
TRUMBULL CT
06611
US

V. Phone/Fax

Practice location:
  • Phone: 203-261-7090
  • Fax:
Mailing address:
  • Phone: 203-218-5767
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number010820
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: