Healthcare Provider Details

I. General information

NPI: 1689256638
Provider Name (Legal Business Name): KELSEY COLETTA LICSW, LCDP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2021
Last Update Date: 11/26/2025
Certification Date: 11/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 CORLISS ST
PROVIDENCE RI
02904-2602
US

IV. Provider business mailing address

200 CORLISS ST
PROVIDENCE RI
02904-2602
US

V. Phone/Fax

Practice location:
  • Phone: 401-606-8530
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDP00947
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberISW04065
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: