Provider Demographics
NPI:1073947990
Name:KELLY, EDILIA P (LAC)
Entity Type:Individual
Prefix:MRS
First Name:EDILIA
Middle Name:P
Last Name:KELLY
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:89 GATE HOUSE LN
Mailing Address - Street 2:
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08820-4011
Mailing Address - Country:US
Mailing Address - Phone:201-956-6363
Mailing Address - Fax:
Practice Address - Street 1:22-08 ROUTE 208
Practice Address - Street 2:
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410-2609
Practice Address - Country:US
Practice Address - Phone:201-956-6363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-27
Last Update Date:2013-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC0017500101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor