Provider Demographics
NPI:1376189480
Name:AMANIERA, KELLY (ATR-BC, NCC, LAC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:AMANIERA
Suffix:
Gender:F
Credentials:ATR-BC, NCC, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 SHERWOOD ST
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07013-1307
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:49 E MIDLAND AVE
Practice Address - Street 2:
Practice Address - City:PARAMUS
Practice Address - State:NJ
Practice Address - Zip Code:07652-2920
Practice Address - Country:US
Practice Address - Phone:551-223-0571
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-24
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
17-254221700000X
NJ37PC00721900101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist