Healthcare Provider Details

I. General information

NPI: 1033414313
Provider Name (Legal Business Name): ETHAN A. KELLY MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2011
Last Update Date: 04/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

263 MAIN ST
OLD SAYBROOK CT
06475-2326
US

IV. Provider business mailing address

263 MAIN ST
OLD SAYBROOK CT
06475-2326
US

V. Phone/Fax

Practice location:
  • Phone: 860-395-6380
  • Fax: 860-395-6382
Mailing address:
  • Phone: 860-395-6380
  • Fax: 860-395-6382

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: