Provider Demographics
NPI:1326150756
Name:KELLY, DOROTHEA SANDRA (MSW, LCSW)
Entity Type:Individual
Prefix:MS
First Name:DOROTHEA
Middle Name:SANDRA
Last Name:KELLY
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:MS
Other - First Name:SANDY
Other - Middle Name:
Other - Last Name:KELLY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSW, LCSW
Mailing Address - Street 1:496 KINGS HWY N
Mailing Address - Street 2:SUITE 223
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08034-1017
Mailing Address - Country:US
Mailing Address - Phone:856-482-2477
Mailing Address - Fax:856-415-0336
Practice Address - Street 1:496 KINGS HWY N
Practice Address - Street 2:SUITE 223
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08034-1017
Practice Address - Country:US
Practice Address - Phone:856-482-2477
Practice Address - Fax:856-415-0336
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC000391001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA2235656000OtherIBC
PA4504459OtherAETNA