Provider Demographics
NPI:1316565476
Name:KELLEY, ALICIA (MSOM, LAC)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:
Last Name:KELLEY
Suffix:
Gender:F
Credentials:MSOM, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 MADELINE LN
Mailing Address - Street 2:
Mailing Address - City:E GREENBUSH
Mailing Address - State:NY
Mailing Address - Zip Code:12061-4233
Mailing Address - Country:US
Mailing Address - Phone:315-521-9769
Mailing Address - Fax:
Practice Address - Street 1:80 E RTE 4 STE 100
Practice Address - Street 2:
Practice Address - City:PARAMUS
Practice Address - State:NJ
Practice Address - Zip Code:07652-2647
Practice Address - Country:US
Practice Address - Phone:201-845-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-06
Last Update Date:2020-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COACU0002244171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist