Healthcare Provider Details

I. General information

NPI: 1265036354
Provider Name (Legal Business Name): KELLIE MORAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2020
Last Update Date: 01/12/2021
Certification Date: 01/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

141 E MAIN ST
WATERBURY CT
06702-2310
US

IV. Provider business mailing address

141 E MAIN ST
WATERBURY CT
06702-2310
US

V. Phone/Fax

Practice location:
  • Phone: 203-574-9000
  • Fax: 203-574-9000
Mailing address:
  • Phone: 203-574-9000
  • Fax: 203-574-9000

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number5564
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: