Healthcare Provider Details

I. General information

NPI: 1487935516
Provider Name (Legal Business Name): ANDREA LEE KELLY M.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2011
Last Update Date: 12/17/2023
Certification Date: 12/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

444 SOUTH UNION ST. SUITE 230
BURLINGTON VT
05401
US

IV. Provider business mailing address

444 SOUTH UNION ST. SUITE #230
BURLINGTON VT
05401
US

V. Phone/Fax

Practice location:
  • Phone: 802-363-9567
  • Fax:
Mailing address:
  • Phone: 802-363-9567
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number047.0000608
License Number StateVT
# 2
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number608
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: