Healthcare Provider Details

I. General information

NPI: 1063352193
Provider Name (Legal Business Name): KELLY LORRAINE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2026
Last Update Date: 03/30/2026
Certification Date: 03/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

91 NORTHWEST DR
PLAINVILLE CT
06062-1534
US

IV. Provider business mailing address

PO BOX 22
WALLINGFORD CT
06492-0022
US

V. Phone/Fax

Practice location:
  • Phone: 888-793-3500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: