Provider Demographics
NPI:1396925897
Name:CASTOR, KELLY LYNN (DTA)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:LYNN
Last Name:CASTOR
Suffix:
Gender:F
Credentials:DTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:242 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EAST WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06088-9519
Mailing Address - Country:US
Mailing Address - Phone:860-670-1383
Mailing Address - Fax:
Practice Address - Street 1:110 COURT ST STE 3
Practice Address - Street 2:
Practice Address - City:CROMWELL
Practice Address - State:CT
Practice Address - Zip Code:06416-1273
Practice Address - Country:US
Practice Address - Phone:860-613-9930
Practice Address - Fax:860-613-9952
Is Sole Proprietor?:No
Enumeration Date:2007-11-13
Last Update Date:2025-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT222Q00000X
222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist