=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770375495
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SELIN KELLY LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/19/2025
-----------------------------------------------------
Last Update Date | 12/05/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1058 PECK LN
-----------------------------------------------------
City | CHESHIRE
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06410-1531
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 475-303-5494
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1058 PECK LN
-----------------------------------------------------
City | CHESHIRE
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06410-1531
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 475-303-5494
-----------------------------------------------------
Fax | 475-275-7227
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 15213
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------