Healthcare Provider Details

I. General information

NPI: 1144930124
Provider Name (Legal Business Name): KELLY MARIE ZANDO LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2022
Last Update Date: 11/30/2022
Certification Date: 11/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 BROOKBEND DR
STRATFORD CT
06614-3011
US

IV. Provider business mailing address

110 BROOKBEND DR
STRATFORD CT
06614-3011
US

V. Phone/Fax

Practice location:
  • Phone: 203-610-7317
  • Fax:
Mailing address:
  • Phone: 203-610-7317
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberMSW.004132
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number4132
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: