Provider Demographics
NPI:1376116871
Name:FAIR, KELLYANN JEAN (LAC)
Entity Type:Individual
Prefix:
First Name:KELLYANN
Middle Name:JEAN
Last Name:FAIR
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 1:233 MCKENZIE ST
Mailing Address - Street 2:
Mailing Address - City:SADDLE BROOK
Mailing Address - State:NJ
Mailing Address - Zip Code:07663-6011
Mailing Address - Country:US
Mailing Address - Phone:201-300-5340
Mailing Address - Fax:
Practice Address - Street 1:233 MCKENZIE ST
Practice Address - Street 2:
Practice Address - City:SADDLE BROOK
Practice Address - State:NJ
Practice Address - Zip Code:07663-6011
Practice Address - Country:US
Practice Address - Phone:201-300-5340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-21
Last Update Date:2023-03-23
Deactivation Date:2021-07-22
Deactivation Code:
Reactivation Date:2023-03-23
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00520700106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist