Provider Demographics
NPI:1033410956
Name:WALTERS, KELLY ROTELLA (PHD)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:ROTELLA
Last Name:WALTERS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 WALTER E FORAN BLVD STE 2002
Mailing Address - Street 2:
Mailing Address - City:FLEMINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08822-4674
Mailing Address - Country:US
Mailing Address - Phone:908-872-3342
Mailing Address - Fax:
Practice Address - Street 1:5 WALTER E FORAN BLVD STE 2002
Practice Address - Street 2:
Practice Address - City:FLEMINGTON
Practice Address - State:NJ
Practice Address - Zip Code:08822-4674
Practice Address - Country:US
Practice Address - Phone:908-872-3342
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-09
Last Update Date:2019-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35SI00528600103TC0700X
103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist