Provider Demographics
NPI:1144991530
Name:PRYOR, KEITH (LPCA)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:PRYOR
Suffix:
Gender:M
Credentials:LPCA
Other - Prefix:
Other - First Name:KEITH
Other - Middle Name:
Other - Last Name:PRYOR
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:16 LANDERS RD
Mailing Address - Street 2:
Mailing Address - City:EAST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06118-3318
Mailing Address - Country:US
Mailing Address - Phone:860-595-2674
Mailing Address - Fax:
Practice Address - Street 1:1080 ELM ST
Practice Address - Street 2:
Practice Address - City:ROCKY HILL
Practice Address - State:CT
Practice Address - Zip Code:06067-1844
Practice Address - Country:US
Practice Address - Phone:860-831-3298
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-24
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5185101YP2500X, 101YM0800X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT17756514Medicaid