Basic Information
| Provider Information | |||||||||
| NPI: | 1720506462 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KELO | ||||||||
| FirstName: | JEANINE | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 47 TOWN ST | ||||||||
| Address2: | |||||||||
| City: | NORWICH | ||||||||
| State: | CT | ||||||||
| PostalCode: | 063602323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8608927042 | ||||||||
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| Practice Location | |||||||||
| Address1: | 245 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | DANIELSON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 062392816 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8609495455 | ||||||||
| FaxNumber: | 8662096522 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2017 | ||||||||
| LastUpdateDate: | 08/04/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 3256 | CT | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.