Provider Demographics
NPI:1184002701
Name:MCAVOY, KELLEY
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:
Last Name:MCAVOY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 BEACON BLVD
Mailing Address - Street 2:
Mailing Address - City:KEANSBURG
Mailing Address - State:NJ
Mailing Address - Zip Code:07734-1937
Mailing Address - Country:US
Mailing Address - Phone:732-865-0978
Mailing Address - Fax:
Practice Address - Street 1:125 BEACON BLVD
Practice Address - Street 2:
Practice Address - City:KEANSBURG
Practice Address - State:NJ
Practice Address - Zip Code:07734-1937
Practice Address - Country:US
Practice Address - Phone:732-865-0978
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-14
Last Update Date:2015-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41YS00797600235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist