Provider Demographics
NPI:1487708384
Name:KELLY, MELISSA ANN (LMFT)
Entity type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:ANN
Last Name:KELLY
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:68 PARISH DRIVE
Mailing Address - Street 2:
Mailing Address - City:KENSINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06037
Mailing Address - Country:US
Mailing Address - Phone:860-828-0110
Mailing Address - Fax:
Practice Address - Street 1:21 NEW BRITAIN AVENUE
Practice Address - Street 2:SUITE 215
Practice Address - City:ROCKY HILL
Practice Address - State:CT
Practice Address - Zip Code:06067
Practice Address - Country:US
Practice Address - Phone:860-529-8977
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001163106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT11668007OtherCAQH PROVIDER NUMBER