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General NPI Number Information
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NPI Number | 1104462654
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Entity Type | Individual
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Provider Name | SHELLEY BETH KINGSBURY LCSW
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Gender | Female
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Dates
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Enumeration Date | 11/20/2019
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Last Update Date | 08/26/2021
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Provider Practice Location Address
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Address Line | 1101 NOANK LEDYARD RD # 12
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City | MYSTIC
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State | CT
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Zip | 06355-1361
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Country | US
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Telephone | 860-861-8393
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Fax |
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Provider Business Mailing Address
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Address Line | 22A AUTUMN VIEW DR
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City | LISBON
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State | CT
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Zip | 06351-2901
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Country | US
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Telephone | 860-861-8393
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 010666
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License Number State | CT
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