Provider Demographics
NPI:1225881436
Name:KELLY, ZOIE BREANNA
Entity Type:Individual
Prefix:
First Name:ZOIE
Middle Name:BREANNA
Last Name:KELLY
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 1:120 RUTGERS ST APT A9
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07109-5502
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1952 US HIGHWAY 22
Practice Address - Street 2:
Practice Address - City:BOUND BROOK
Practice Address - State:NJ
Practice Address - Zip Code:08805-1545
Practice Address - Country:US
Practice Address - Phone:908-967-6214
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-08
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician