Healthcare Provider Details

I. General information

NPI: 1699448647
Provider Name (Legal Business Name): KAITLYN KEDDY LPCA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2021
Last Update Date: 07/27/2021
Certification Date: 07/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

540 LITCHFIELD ST
TORRINGTON CT
06790-6679
US

IV. Provider business mailing address

21 IRVING ST APT 4
BRISTOL CT
06010-4187
US

V. Phone/Fax

Practice location:
  • Phone: 860-496-6350
  • Fax:
Mailing address:
  • Phone: 860-845-4394
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number5010
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: